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Copy the application below and paste onto any Microsoft Word Document.

 

 

 

Irminen-Gesellschaft

Application for Membership

 

 

Type of Membership (circle one):    Individual      Individual with Spouse

 

Full Legal Name (required):  _____________________________

If you would prefer to be referred to by a Given or „spiritual“ name, please provide it:
_______________________________

Name of Spouse (if applicable): _____________________________
 

Street Address/ PO Box: ___________________________________________

Town or City: ___________________________________________

Zip/postal code:  ___________________________________________

State or province:  ___________________________________________

Country:  ___________________________________________

E-mail address:  ___________________________________________
Fax number:  ___________________________________________

 

Would you prefer that your address remain private?    Circle one:   yes   no
 

Have you or your spouse ever been convicted of a felony and / or confined to a mental facility?    yes         no 
 

Mailing address

[if different from above, or the address you prefer to share with other members]:
 

Street Address/ PO Box: ___________________________________________

Town or City: ___________________________________________

Zip/postal code:  ___________________________________________

State or province:  ___________________________________________

Country:  ___________________________________________

E-mail address:  ___________________________________________
Fax number:  ___________________________________________

Phone Number

Please include area and country code(s) [if applicable]:

 _______________________________

Can we share your phone number with the regional representatives in your area (if applicable)?    yes    no

Date of birth:  ___ /___  /___    

Date of birth of Spouse (if applicable) :  ___ /___  /___      
[Required! You must be at least 18 years of age or have a parent's consent]

Do you practice Irminenschaft?  yes   no

If no, what religious path do you follow? ________________________________________________

 

What do you feel makes you an asset to the Irminen-Gesellschaft?
[attach another sheet of paper if needed]

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Can you tell us anything more about yourself?

[attach another sheet of paper if needed]

_______________________________________________________________________________________

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Annual Dues

 

Please include the applicable dues in US funds with your application, payable to Irminen-Gesellschaft. Funds may also be sent via PayPal.

If your membership is rejected for any reason, your money will be returned to you.

Individual: $25.00 / Individual with spouse: $35.00 per year


 

 

 

 

 

 

 

 

 

I certify that the information above is correct, that I do agree with the principles of the Irminen-Gesellschaft as outlined, and acknowledge that the Irminen-Gesellschaft retains the right to deny my application for any reason. I also acknowledge that I am a legal citizen of the country/province/state in which I reside, and am not being currently sought by any authority in connection to a criminal act, nor am I currently facing criminal charges in any jurisdiction.

 

 

Signature [required]: _____________________________________ Date: ___/___/___

 

 

Signature of Spouse, if applicable [required]:

 

 

_____________________________________ Date: ___/___/___

 

 

 

Parent's Consent: I, _________________________________ the (custodial) parent or Legal guardian of _________________________________ give my consent for him/her to become a member of the Irminen-Gesellschaft, and to participate in functions or activities of the Gesellschaft, and acknowledge that my child will receive regular mailings and information from the Irminen-Gesellschaft during his or her membership, and that he or she receives that information under my discretion and direct supervision and with my full knowledge and approval-

 

 

 

Signature [required]: ___________________________________ Date: ___ / ___ / ___

Copyright © 2001-2008 Irminen-Gesellschaft
Last updated: 21 Heumond 08