| Application for Membership in the Netherlands American Society (NAS) PLEASE PRINT, COMPLETE AND MAIL THIS FORM AS OUTLINED BELOW All information provided will be maintained solely within the Netherlands American Society. |
| __ New Application | __ Change of Address, Tel, etc. | |
| Birthdate (Mo/Day) | ||
| Mr./Mrs./Ms. | ____________________________________________ | ___/___ |
| & Mr./Mrs./Ms. | ____________________________________________ | ___/___ |
| Occupations: | ______________________ | _____________________ |
| Telephone (H): | ____________________ (B): ____________________ |
| Fax: | _________________ E-mail: ____________________ |
| Address: | ____________________________________________ |
| City, State, Zip/Postal Code: | ____________________________________________ |
| Country: | ____________________________________________ |
| Anniversary (Mo/Day/Yr): | ____ / ____ / ____ |
| Introduced to NAS by: | ____________________________________________ |
| Signature: | ______________________________ Date:_________ |
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New members agree to adhere to the rules and regulations as stated in the Bylaws of the Netherlands American Society. The annual dues are $30.00 per person or $50.00 per couple.
Please send your completed application form with a check for the appropriate dues amount made payable to NAS, to: Ada Horstin - NAS TREASURER
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