Application Date ________________. Prefered Title (Dr/Mr/Mrs/Ms/Rank) _______________

Name __________________________________________ Date of Birth  _______________
                     (First)        (Middle)         (Last)                                                  (DD/MM/YY)

Mailing Address _____________________________________________________________
                                         (Box-Route-StreetNumber-StreetName-Apartment Number)

                           ____________________________________________________________     
                                         (City )                  (Province / State)     (Country )      (ZIP+4)


Branch / Family Affiliation / Sept  (if known, but not required) __________________________

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 *  Submission of the following information is  optional and solely for use by  CSSA *

 (Membership data is not provided to commercial enterprises nor government agencies)  

* Spouse Name________________* Children Name(s)_____________________________

* Occupation ____________________  * Fields of Expertise  ________________________

* Areas of Interest _____________________  *Skills/Talents ________________________

* Are You Willing to Assist the Society at Local Cultural Events?    (Circle  Y  or   N )    

* Telephone ______________________________________________________________
                       (Home: Area Code + Number)    &      (Work: Area Code + Number)

* E- Mail Address ______________@_______________    *URL ___________________

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 Membership Category  ('X')  ANNUAL (U$15)___     LIFE (U$225)___ 

Enclosed: U$ ________  [Check or Money Order Made Payable to CSSA, INC.] 

Mail to:

SECRETARY - CSSA, Inc.   
P. O. Box 9538 
Knoxville, TN 37940