PLEASE NOTE: By default, all certificates contain electronic signatures of the current President General and Secretary General, as well as the member’s State Society at the time of approval. To obtain State officers’ signatures, membership certificates will first be mailed to the State Society where the membership originated (even if the member later transferred to a different State Society). The certificate will then be forwarded to you by that State Society. Supplemental certificates will be mailed directly to you. COST: $10.00 each • Make check payable to NSSAR Treasurer General. (Check must accompany order.) Mail check to: NSSAR, 1000 S. 4th Street, Louisville, KY 40203 Questions? Contact Aaron Adams, Registrar, 502-589-1776 (ext 20) or aadamssar [dot] org

Member Information

First Name: *

Middle Name:

Surname (Last Name): *

National Number: *

State Number:

State Society: * select...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDakota (North & South)DelawareDistrict of ColumbiaFloridaFranceGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMexicoMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew York (Empire State)North CarolinaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSpainTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Approval Date: *

Day12345678910111213141516171819202122232425262728293031

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Year194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050

Request Details

Reason For Request: *

Please give a short explanation as to why you are requesting a new certificate

Certificate Type: * select...Membership CertificateSupplemental Ancestor Certificate

Patriot Ancestor's Name: *

Please provide the name of your ancestor that you are requesting the Certificate for. Supplemental Certificates are for additional ancestors for whom supplemental applications were approved, in addition to the ancestor upon whom original membership was based. If more than one supplemental ancestor certificate is being requested, please complete separate forms for each.

Mailing Info

Provide your current mailing information

Name: *

Street Address: *

City: *

State: *

Zip Code: *

Daytime Phone #: *