Please print this form and fill out all information and
fax it to us at (516)742-7086
or copy and paste in e-mail to ireusa1@aol.com
MEMBERSHIP APPLICATION
Date____________________ Telephone Number _____________________
Name___________________________________________________________
Address_________________________________________________________
City_____________________________State____________Zip____________
Occupation________________________________________Single Married
Place of Birth______________________________________Citizen: Yes No
Fathers Name____________________________________________________
Mothers Maiden Name_____________________________________________
Proposed by___________________________________________
Present Members Signature
Seconded by__________________________________________
Present Members Signature
I hereby request membership in the IRISH-AMERICAN SOCIETY OF NASSAU, SUFFOLK & QUEENS, INC. I am aware the signing of this application does not mean that I have been accepted as a member.
Applicants Signature______________________________________________
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For Office Use
Date Approved___________By______________________________________
Chairman Membership Committee
516-746-9392 or 516-742-8080
Society Membership