PRINTABLE APPLICATION FORM

SECTION I

Title(s): Mr. Mrs. Miss Dr. Rev. The Hon. Lt. Col. Other

Name: (First, Middle, Last):

Street Address:

City:

State: Select a State Alabama Alaska Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Indiana Illinois Iowa Kansas Kentucky Louisiana Massachusetts Maine Maryland Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming    County (not Country):    Zip/Postal:

Country: --select-- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzogovinia Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, Democratic Republic of the Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Johnston Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgystan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia, FYR of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Midway Islands Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard & Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands Wake Island Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe

Telephone:  E-mail:

Design a new coat of arms for my personal use and to Register and Publish the same.

Register and Publish the coat of arms I now have which has not yet been granted, registered, certified, or otherwise recognized for my personal use by a domestic or foreign office of arms.

Register and Publish the coat of arms I now have which were:

Granted Registered Certified Otherwise recognized for my personal use by a domestic or foreign office of arms*

* I am enclosing information verifying this armorial recognition.

I am not requesting a Registration of Arms at this time.

STOP HERE IF YOU ARE ONLY APPLYING FOR ANNUAL MEMBERSHIP

SCROLL DOWN TO COMPLETE PAYMENT INFORMATION AND PRINT THIS FORM

Date of Birth:

Date of Legal Adoption:

City, County and State of Birth:

Marital Status: Married Never Married Widowed Divorced Other

Sex: Male Female

Education:

Present Occupation(s), Position(s), Profession(s) - Please attach/email a business resume if available.

List highest rank held and major decorations received:

Public Office: (List offices held, past or present, by election or appointment. Clearly indicate whether each office is at City, County, State, Federal or other level. State dates when each office was entered and when each was vacated.)

List:

1. the Religious faith and Denomination to which you belong
   
2. the specific congregation or parish you currently attend
   

List Membership in Organizations, Societies, Associations, Clubs, etc.:

List hobbies, avocations and interests:

List Orders of Knighthood & Nobiliary Associations (please include (a) the full name of the Order; (b) your rank in it; (c) your appropriate postnominals; (d) please enclose photocopies of brevets):

Full name of your Father: (First, Middle, Last):

List dates of his birth:   his death:

Full MAIDEN name of your Mother: (First, Middle, Last):

List date of her birth:   her death:

Full MAIDEN name of your Spouse: (First, Middle, Last):

List date of her birth:   her death:

Children born to or adopted by you and the above named spouse:

NOTE: Should you have any children whatsoever by previous marriages, it is VITAL that you enclose full information on both children and their mother(s) as noted in the last question. Further, if this registration is for someone who is a grandfather, then include all eligible descendants (attach a separate page if necessary), such as all children of the armiger, as well as all of the children of those children. Please be sure to include MAIDEN names of any spouses as parents of additional children.

Please forward a separate sheet on any additional biographical data which you feel may be helpful. I hereby certify that all biographical data contained in this application is accurate to the best of my knowledge.

Signature _________________________________________    Date ________________________________

Please print out and mail or fax this completed application, along with any of the applicable funds as indicated in the above section on fees. PLEASE NOTE THAT SOME TEXT BOXES MAY NOT BE LARGE ENOUGH TO COMPLETELY DISPLAY THE INFORMATION YOU ENTER - PLEASE REVIEW YOUR APPLICATION THOROUGHLY TO ENSURE ALL INFORMATION IS DISPLAYED COMPLETELY AND CORRECTLY

METHOD OF PAYMENT:

Check or Money Order made payable to THE AMERICAN COLLEGE OF HERALDRY

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IMPORTANT- CHECK THIS BOX IF YOU HAVE PAID ONLINE, RATHER THAN INCLUDING PAYMENT HERE

Copyright © 2008 The American College of Heraldry