Membership Form
Association des Brochu d'Amérique

I wish to join the Association des Brochu d'Amérique as a member :

Regular (yearly membership) :        20 $CAN    /20 *$USD

3 years (payment for 3 years) :   50 $CAN    /50 $USD

Life membership (one payment) :   300 $CAN    /300 $USD

Donation (Heritage fund):   _______

Amount: ______________


Name : ___________________________________________________

Birth date : _____________________________

Address : ________________________________________________

City : ___________________________________________________

Province /State : _______________________________________

Postal Code : ___________________________

Phone Number : ______________________   E-mail : ______________________________


Tell us more about your family:

Father's name : _______________________ Mother's name : ___________________________

Place of residence : ____________________________________

Where did they get married? ________________________________

If they died, when and where :

Father : ___________________ _________________________

Mother : ___________________ ________________________

Grandfather's name : _______________________ Grandmother's name : ______________________

Where did they live? ____________________________________

Where did they get married?_________________________________

Name of your husband / wife :______________________________________

Language of correspondance: _________________________


Please print and send the form with your check to: :

Association des Brochu d'Amérique
C. P. 10090, Succ. Sainte-Foy
Quebec (Quebec)
CANADA   G1V 4C6

THANK YOU!