.19^ 



The Secretary, 

 Societe Provencher d'Histoire Naturelle du Canada, 

 Universite Laval, Quebec 



I have read carefully the regulations of the SOCIETE 

 PROVENCHER D'HISTOIRE NATURELLE DU CANADA 

 of which I desire to become a (a) member. 



• As soon as advised of my admission I will foncard the amount 

 of my contribution, $ 



Name 



Address . 



Profession 



(a) Benefactor, patron, life or active, as per art. 15 of regulations 



