Name:	__________________________________________________
Street Address:	__________________________________________________
City, State and Zip Code:	__________________________________________________
Country:	__________________________________________________
Telephone:	__________________________________________________
E-mail Address:	__________________________________________________
Name desired on your membership certificate:	__________________________________________________
I understand that: I am applying for a regular membership to The Clan MacCarthy Society. I will be entitled to all the benefits of that membership, as specified by the Society on their website. My membership is an annual membership based on the calander year. The annual membership fee is 25 US dollars, due on January 1st.
Signature:	__________________________________________________
Date:	__________________________________________________

Would you be interested in serving as an officer, board member or committee member?
(   ) Yes    (   ) No

All officers, board and committee members will donate their time and be responsible for managing the policy affairs of the society.  Do you have any special skills (i.e., writing, designing, computers, networking) which you would be interested in sharing with the society?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Please make your cheque out to The Clan MacCarthy Society, Inc..

Mail this application and your check to

:

Lawrence J. McCarthy, President The Clan MacCarthy Society P.O. Box 69 Plains, MT  59859 U.S.A.

( This application is designed to be printed out from a browser, with 0.5" margins. )