Ontario Basque Club - Membership Application/Renewal Form


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membership form

Last Name:

First Name:

Address:

City

State

Zip Code

Phone Number: (xxx-xxx-xxxx)

Email Address:

Year of birth

Citizen of: (According to passport)USASpainFranceOther

Your Basque origin, or that of your ancestor(s). Check all that apply: BizkaiaGipuzkoaArabaNafarroaLapurdiBaxenabarreXiberuadon't know

Which generation of your family immigrated from the Basque Country? I didmy parent(s)grandparent(s)great-grandparent(s)great great grandparent(s)more distant

Basque Languagespeak understand read write

Spanish Languagespeak understand read write

French Languagespeak understandreadwrite

Type of Membership:single ($10.00)family ($25.00)

Family Member 2:

year of birth

Basque Language:speak understandreadwrite

Other LanguagesSpanishFrenchother

Family Member 3:

Year of Birth

Basque Languagespeak understandreadwrite

Other LanguagesSpanishFrenchOther

Family Member 4:

Year of Birth

Basque Languagespeak understandreadwrite

Other languages:SpanishFrenchOther

Family Member 5:

Year of Birth

Basque Language:speakunderstandreadwrite

Other Languages:SpanishFrenchOther

Family Member 6:

Birth Year:

Basque Language:speakunderstandreadwrite

Other Languages:SpanishFrenchOther