Supplemental Application

Date:
MM slash DD slash YYYY
Applicant's Name*
Maiden Name: (if applicable)
Street Address:*
City
State
Zip Code
Home Phone or Cell #*
Email Address*
Occupation*
Name of Mayflower Ancestor(s)*
Names of Relatives who were/are Members, GS & State #'s of the Mayflower Society in New York or any other Society. This information will be helpful in filling out your lineage from, but is not required.*
Names of Relatives who were/are Members, GS & State #'s of the Mayflower Society in New York or any other Society. This information will be helpful in filling out your lineage from, but is not required.
Signature

Signature
Date of Sumittal

Date of Sumittal
Please include $150.00 payment for the application fee.
The application fee is not refundable if the line is rejected, the application is rejected, or if the applicant fails to complete the documentation.

Complete the form, print and mail to:
The Society of Mayflower Descendants in the State of NY

20 West 44th Street

New York, NY 10036-6603