Membership Record Form

Clann Aodhagain - USA/Canada

 An individual membership is $15 per year or $25 for all family members at one address.  You may also wish to contribute to the "Egan Pence," which is for use of Clan USA/Canada in supporting the International Clan Egan Association in Ireland.
 
Check one:___Family membership
___Individual membership
Family name:____________________
Names of adults at this address: 
__________________________________ 
__________________________________ 
__________________________________ 
__________________________________ 
__________________________________
Your name:__________________________
Permanent Address: 
Street:______________________________ 
____________________________________ 
City:____________State/Prov:__________ 
Zip or Postal Code:___________________ 
Country:____________________________
Alternate Address (and months): 
Street:______________________________ 
____________________________________ 
City:____________State/Prov:__________ 
Zip or Postal Code:___________________ 
Country:____________________________
Phone#: H:_____________W:___________ 
Fax#:___________________ 
E-Mail:_____________________________
Alternate: 
Phone#: H:_____________W:___________ 
Fax#:___________________ 
E-Mail:_____________________________ 
Member since:_______ Relative who will re-establish contact if mail is returned:
Name:________________________

Street:______________________________ 
____________________________________ 
City:____________State/Prov:__________ 
Zip or Postal Code:___________________ 
Country:____________________________

Membership Fee:
___$25 family membership enclosed
___$15 individual membership enclosed
$_____Egan Pence Contribution
Notes:
 
The Clan Archivist would like you to enclose a copy of your pedigree.

 Print this form, fill it out, and mail it, along with your check or money order, to:

James Eagen
4610 Brad Court
Rockville, MD 20853