Print out this form and mail to the address below

Name: (Mr. Mrs. or Ms.) _____________________________________________________

Address _____________________________________________________________________

City ____________________________________ State ___________ Zip _____________

Telephone Number (    ) _____________________________________________________

e-mail address ______________________________________________________________

[ ] Renewal:  Annual Dues are $12.00 per address payable May 1 each year

[ ] Addresses outside of the United States: add $5.00 for first class postage

[ ] New Member: Dues for new members (first year) are pro-rated at $1.00
                      per month beginning on June 1; example: May - $12.00;
                      June - $11.00; July - $10.00; etc. except January
                      through April minimum dues are $4.00

[ ] Lifetime: Lifetime dues are $120.00

Cornish Surnames researching:  Please print PLAINLY ________

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Area in Cornwall of family origin: _______________________________________

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Version: 6- 21-08