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Mid Winter Meeting

Honorable Order of the Blue Goose International 

Application for the New York City Pond

1st year dues of 50.00 must be attached 

Check made out to: Honorable Order of the Blue Goose

Personal Information:                

Last Name:___________________________First name:______________________

MI:__________________ Nickname:__________________________

Date of Birth:________________ Spouses's Full Name______________________

Home Address:_______________________________________________________


Home Number:_____________________Work Number:______________________

Professional Information:

Employer Name:__________________________________________________

Work E-mail Address_______________________________________________

Work Address:______________________________________City:_______________

State:______Zip Code_____________

Work Number:_____________________Fax Number:_______________________

I prefer mail being forwarded to my      ___Home     ___Work ( Please check)

Have you ever been a member of another pond?   ___Yes  ___No   if yes where________________________ Flight to:_______________________pond from__________________________ and has paid dues for the Fiscal year ending________________________ 

If officier,postion held:____________________________Dates:____________________________

Applicant's Signature:________________________________________

New Member Vouched for by Three Ganders

1____________________________     ________________________________

2____________________________     ________________________________

3____________________________     ________________________________

Print Sponsor's Name above              Sponsor's Signature above      

Pond Use Only: Dated:____________________

Approved by:_________________WGQ

Please send to: Independent Adjustment Company Michael Nardulli 

22 West Main Street Suite 14 Patchogue, NY 11772