CLAN KEITH SOCIETY OF CANADA
           		APPLICATION FOR MEMBERSHIP

If you are affiliated with any of the surname(s) listed below, the

Clan Keith Society of Canada invites you to apply, and to become part of,

one of the great historical clans of Scotland. (Please circle one)

AUSTIN, DICKSON, DIXON, DIXSON, FALCONER, FAULKNER, HARVIE,

HARVEY, HAXTON, HURRIE, KEITH, KEETH, LUMGAIR, MACKEITH,

MARSHALL, URIE, URRY (Spellings may vary)

______________________  ______________________  ______________________
Name                    Place of Birth          Date of Birth

Street:__________________________       City:_________________________

Province:_____________________          Postal Code:_________________ 

Phone Number:___________________	Email:________________________       

______________________________________________  ______________________  

Mothers Name            			Mothers Maiden 
______________________________________________________________________

Fathers Name         
_____________________________________________  ______________________  

Grandmothers Name   				Grandmothers Maiden 
_____________________________________________________________________

Grandfathers Name     

                      Annual Fee Schedule 

Please indicate the type of membership desired, submit completed forms 
and your cheque payable to Clan Keith Society, Canada. 

_____Individual 1 year membership - $20.00 

_____Household  1 year membership - $25.00 


Signature:_____________________________  Date:______________________

PLEASE SEND COMPLETED FORMS WITH PAYMENT TO:
Clan Keith Society, Canada
c/o Marianne Weese
33 Dench Ln., R.R. #3
Frankford, Ontario K0K-2C0