THE AVERY MEMORIAL ASSOCIATION

MEMBERSHIP APPLICATION

NAME: [ ] Mr. [ ] Mrs. [ ] Miss [ ] Ms.________________________________________

STREET ADDRESS: ______________________________________________________

CITY: __________________________ STATE: ________ ZIP CODE:_______________

TELEPHONE NUMBER: ___________________________________________________

E-MAIL ADDRESS: _______________________________________________________

Choice of Dues*: Annual = $25 per year OR Lifetime Dues = $500
(*Dues increased on July 1, 2008)

Dues are payable in U.S. Dollars only. Donations of money or material to the Association
are deductible, within legal limits, for Federal tax purposes.
Please make your check payable to "The Avery Memorial Association."

Membership Categories (check one):

[__] Friends of The Avery Memorial Association - Fill in the above information ONLY and send in application with your choice of dues to The Avery Memorial Association, P.O. Box 7245, Groton, CT 06340-7245.

[__] Active Member (Descendant of Christopher Avery) - Fill in the above information AND the rest of this application and send application with your choice of dues to The Avery Memorial Association, P.O. Box 7245, Groton, CT 06340-7245.

I WAS BORN AT: ____________________________ ON ______________________

MARRIED TO: ______________________________ ON ______________________

SPOUSE BORN AT: __________________________ ON ______________________

CHILDREN: __________________________________________________________

FATHER OR MOTHER ON AVERY SIDE: ________________________________

I certify that the above information is correct to the best of my knowledge and belief.

Signed:_____________________________

Date of Signing:_____________________


In the following Genealogy, please cite "The Groton Avery Clan" number of your early ancestors and/or note other sources:


Third Generation

Son:

Date & Place born:

Daughter:

Date & Place born:

Who married:

Date & Place of Marriage:


Fourth Generation

Son:

Date & Place born:

Daughter:

Date & Place born:

Who married:

Date & Place of Marriage:


Fifth Generation

Son:

Date & Place born:

Daughter:

Date & Place born:

Who married:

Date & Place of Marriage:


Sixth Generation

Son:

Date & Place born:

Daughter:

Date & Place born:

Who married:

Date & Place of Marriage:


Seventh Generation

Son:

Date & Place born:

Daughter:

Date & Place born:

Who married:

Date & Place of Marriage:


Eighth Generation

Son:

Date & Place born:

Daughter:

Date & Place born:

Who married:

Date & Place of Marriage:


Ninth Generation

Son:

Date & Place born:

Daughter:

Date & Place born:

Who married:

Date & Place of Marriage:


Tenth Generation

Son:

Date & Place born:

Daughter:

Date & Place born:

Who married:

Date & Place of Marriage:


Eleventh Generation

Son:

Date & Place born:

Daughter:

Date & Place born:

Who married:

Date & Place of Marriage:


Twelfth Generation

Son:

Date & Place born:

Daughter:

Date & Place born:

Who married:

Date & Place of Marriage:


Thirteenth Generation

Son:

Date & Place born:

Daughter:

Date & Place born:

Who married:

Date & Place of Marriage:


Please write additional generations beyond 13th on a separate piece of paper and enclose with application.


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