Mother Lode Scots
Membership & Dues

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First Name Last Name
Address
CityState ..Zip
Phone Email
Date of Birth
Clan(s)

Additional Family Members
Please list first & last names
of each person,
clan and date of birth,
one name per line



Membership Selection and Dues

Indicate Number of Memberships & Badges Junior.......................$10.00
Individual................$20.00
Family......................$30.00
Name Badge..........$20.00




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