Nickerson Family Association
Membership Application
Full Name:
Date of Birth:
Place of Birth:
Children Under 16
Name
Date of Birth
Address:
City:
State:
Zip Code:
Country:
Email:
Telephone:
Enclosed is a check or money order for my membership dues (please check one):
Sorry, U.S. funds only
Annual Single Membership
$20.00
Annual Family Membership
(Husband and Wife)
(Add $1.00 per child 16 or under)
$30.00
+ $ for children.
Lifetime Membership
$250.00
Print out your completed application and mail it along with your genealogical to: Membership Chairperson
c/o Nickerson Family Association, Inc.
P.O. Box 296, 1107 Orleans Road
North Chatham, MA, 02650-0296
U.S.A.
