BELFAST 

 Natural History and Philosophical Society. 



i 



Founded 5th June, 1821. 



APPLICATION FORM FOR MEMBERSHIP. 



To be 



filled up 



by the 



Candidate. 



Name, etc. 



[Please write name in full.] 



Description 

 Residence 



, being desirous of becoming a Member 



of the Society, I, the undersigned member, recommend 

 as a suitable candidate for election. 



Dated this day of 



gnature c 

 Member 



19. 



Signature of | 



[Candidate must be known to the Member signing this form.] 

 \,All applications are subject to the approval of the Council] 



Received 



Elected by 1 

 Council / 



