Name : __________________________________________________   Date : _______________

Address : ____________________________________________________________________

City : ___________________________________________   State : _____   Zip : ______________

E-mail Address : _______________________________________________________________

Denominational Affiliation (optional): ________________________________________________

Membership amount enclosed $ ____________ ($12.00 per year)
      ____ Renewal (due January 1)
      ____ New

Make check payable to: mail to:

FELLOWSHIP OF BRETHREN GENEALOGISTS Tom Crago 6759 Showhorse Court Colorado Springs, CO  80922-3314

Family surnames : __________________________________________________________

________________________________________________________________________
(List surnames alphabetically. Please do not re-list previously submitted.)
If a membership card is desired, please enclose a SASE (Self- Addressed, Stamped Envelope).