Honorable Order of the Blue Goose, International

September 3, 2010

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Please fill out the following form to apply for membership in the Honorable Order of the Blue Goose, Intl.

Pond

Date

Applicant's Name *

Mailing Address *

City *

State or Province *

Zip or Postal Code *

Country *

Email *

Residential Phone

Business Phone

Cell Phone

Fax

Date of Birth *

Employed By *

Occupation *

Spouse's Name

Ever been a member of a Pond? Yes No
If so, name of the Pond?

* Required Information

Acceptance of application by Grand Nest is based on acceptance of Pond and vouched for by 3 Ganders.

Entertaining a high regard for the aims and objects of the Honorable Order of the Blue Goose, International and promising to abide by the Constitution and By–Laws, if admitted to membership, I hereby submit my application for membership.