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| I hereby apply for membership in the EMERALD SOCIETY of the State of New Jersey, and make each of the following statements of facts, personally known to me, intending that the Society rely upon the truth of each in acting upon this application: (Please submit appropriate dues-See Requirements for Membership Page) |
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| Name_________________________________ |
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| Address___________________________________ |
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| City/Town__________________________________ |
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| State/Zip___________________________________ |
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| Home Phone________________________________ |
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| Age______________ Date of Birth_______________ |
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| email address______________________________ |
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| On what do you base your Irish Ancestry?_____________ |
| _______________________________________________ |
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| Applicant Recommended By:__________________________ |
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| Agency Employed By/Emerald Society Member of: |
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| _________________________________ |
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| Address:__________________________ |
| _________________________________ |
| Phone_____________________Fax__________________Rank_______ |
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| If elected to membership I agree to abide by and be governed by the present Constitution and By-Laws of the Emerald Society and any future amendments, modifications and changes thereto. |
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| Signature_____________________ |
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| Name of Sponsor:_________________________________ |
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| First Reading Date______________ Second Reading Date_____________ |
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| Elected to Membership Date_____________________ |
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