MEMBERSHIP APPLICATION for the Nipmuc Indian Association of Connecticut
MEMBERSHIP APPLICATION
for the Nipmuc Indian Association of Connecticut
For the Calendar Year ____ (fill in)

(Please Print Clearly)

Today's Date:_______________ Your Date of Birth:_______________
Month / Day / YearMonth / Day / Year
Name:______________________________ Telephone:(____) _____-________

Mailing Address: __________________________________________________

City: __________________________ State: ________ Zip Code:____________

Member Type:


[ ] Nipmuc Native American
- Certification # (if any) __________________________
[ ] Native American - Tribe(s)______________________
[ ] Friend of the Nipmuc Indians

My additional Donation of $________ is enclosed, for a total of $_________.

Yearly Dues are $12.00 per person. Please send full payment in with your Application for Membership.

Please make your check or money order payable to NIAC and mail it with your completed form to:

Secretary
Nipmuc Indian Association of CT
Box 411
Thompson, CT 06277-0411


We appreciate your support!

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