Date ___________________

Name (Mr. Mrs. or Ms.) ____________________________________________________________

Name as it should appear on badge (if different from above) _______________________

Spouse's Name (Mr. Mrs. or Ms.) ___________________________________________________

Street ____________________________________________________________________________

City ________________________________  PROV ___________  POSTAL CODE ______________

Telephone Number (     ) __________________________________________________________

E-mail Address ____________________________________________________________________


Annual dues are $18.00 per address payable June 1 of each year.



Make cheques payable to:                      For further information contact: 
  Toronto Cornish Association                   The Membership Secretary
and mail it to:                                 25 Queensgrove Rd
  The Membership Secretary                      Scarborough, ON  M1N 3A9
                                                Canada  


Surname Interest / Parish or Town / Approximate Period 

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