Membership Application

Membership Status*

New Member
Renewing Member

Name*

Title First Last Maiden Name

Email*

Enter Email Confirm Email

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name as I would like it to appear on my membership certificate

The Homestead Courier - FFA Newsletter Preferences*

by email
by US Mail

Membership in other Societies

I would like to know more about

Taking an active role in the Fairbanks Family in America, Inc.
Volunteering at the Fairbanks House

I am*

a Descendant
not a Descendant

I am a*

Direct Descendant
Spouse of Direct Descendant

I was born on*

I was born in*

My last Fairbank(s) ancestor*

Page

Number

My Spouse's Name

First Last

Spouse's DOB

We were married on

We were married in

Are You Still Married?

Yes
No

Reason

Death
Divorce

Date of Death

Date of Divorce

Did you remarry?

Yes
No

My Second Spouse's Name

First Last

Second Spouse's DOB

We were married on

We were married in

Second Spouse - Are You Still Married?

Yes
No

Second Spouse - Reason

Death
Divorce

Second Spouse - Date of Death

Second Spouse - Date of Divorce

Membership Application

Step 1: Please tell us a little about your self…