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