HONOBABLE ORDER OF THE BLUE GOOSE, INTERNATIONAL
NEW MEMBERSHIP APPLICATION
Make check for $50 payable to "Florida Pond-Blue Goose" or
pay with a credit card using PayPal at http://flpond.homestead.com
* - Indicates required field
Applicant's Name* ___________________________________________________________________
Applicant's Address* _________________________________________________________________
Applicant's City/State/Zip* _____________________________________________________________
e-mail* _____________________________________________________________________________
(if none, please provide a phone number for contact)
Home PhoneBusiness PhoneCell Phone( ) ______-________ ( ) ______-________ ( ) ______-________
Employer* _________________________________________________________________________
Occupation* ________________________________________________________________________
Date of Birth*Spouse's Name (optional)Ever been a member of the Order?*
Spouse's Name (optional)Ever been a member of the Order?*______/______/_________ ____________________________ ( ) Yes( ) No
( ) NoEntertaining a high regard for the aims and objects of the Honorable Order of the Blue Goose, International and promising to abide by the Constitution and By-Laws, if admitted to membership, I hereby submit my application for membership.
X___________________________________ ________/________/____________
________/________/____________Signature of Applicant* Date
Date NEW MEMBER MUST BE VOUCHED FOR BY THREE GANDERS
Signature Print Name
Print Name (1) __________________________________________________ (1) ____________________________________
(2) __________________________________________________ (2) ____________________________________
(3) __________________________________________________ (3) ____________________________________
______/______/________ ________________________________________
Date Initiated Wielder of the Goose Quill or Puddle
Wielder of the Goose Quill or Puddle