Pioneer Certificate Application

Section 1

Applicant's name: ___________________________________________________________
Name to appear on certificate

Mailing address:____________________________________________________________
Address to which the certificate will be sent:________________________________________

Applicant's Birth date & place : (optional)___________________________________________

Applicant's Spouse's name: (optional) ______________________________________________

Section 2

Pioneer Ancestor's name: ____________________________________________________
Name to appear on certificate________________________________________________
Pioneer Ancestor's Birth date & place:__________________________________________

Pioneer Ancestor's Spouse's name:____________________________________________

Pioneer Ancestor's Marriage date & place:_______________________________________

Pioneer Ancestor came to _______________________________________ North Dakota
town _____________ township _______________ county _____________
on __________________________ from _________________________________________
date __________________ former residence ____________________

Section 3

Please fill in the names of intervening generations between the applicant and the pioneer ancestor.

Applicant is son/daughter of __________________________________________________
and spouse:__________________________________________________________

Applicant is grandson/granddaughter of_________________________________________
and spouse:__________________________________________________________

Applicant is great grandson/great granddaughter of _______________________________
and spouse:__________________________________________________________

Applicant is 2 great grandson/ 2 great granddaughter of____________________________
and spouse:__________________________________________________________

Applicant is 3 great grandson/3 great granddaughter of____________________________
and spouse:__________________________________________________________

I understand that the application and proofs submitted become property of the Red River Valley Genea-logical Society. I give my permission for their use in future Society publications. (Please sign) ______________________________________________________________________________

Send completed application, copies of proofs, $8/application fee to:

Red River Valley Genealogical Society, PO Box 9284, Fargo, ND 58106-9284