INSTRUCTIONS TO APPLICANT: Fill in sections D, E, and F on this page. List your main ancestral line on pages 2 and 3, beginning with your self as #1. Type or write all information legibly. A check for $15.00 (non-refundable) must accompany this application.
| BCGS USE ONLY 1._____________________ 2. ____________________ 3. ____________________ 4. ____________________ 5. ____________________ 6. ____________________ 7. ____________________ | | BCGS USE ONLY Date application Received _____________ Acceptance Date __________ Fee Received _____________ |
[D]Applicant's Name:__________________________________________________________ Address:_________________________________________________ City:_________________________________ State:____ County:_________________ Zip+4:_____________ Telephone: (____) __________________ Email Address:_________________________________________________________________________ |
| Full Name of Husband or Wife |
[E] ANCESTORS WHO WERE SETTLED IN BELMONT COUNTY BY 1851
| Name of Ancestor | Year first proved in Belmont County | Twp first proved in Belmont County | State or County Ancestor came from |
___________________________________________________________________________
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___________________________________________________________________________
___________________________________________________________________________
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| Pioneer Families of BCGS Committe Chairman _________________ | Date ________ |
| BCGS President _________________ | Date _____________ |
1. I,________________________________ was born on_______________________________ at City____________________________ County__________________ State___________
2. I am the child of_____________________________________________________________ born on_______________________________ at City____________________________ County__________________ State___________ died on_______________________________ at City____________________________ County__________________ State___________ and __________________________________________________ his wife born on_______________________________ at City____________________________ County__________________ State___________ died on _______________ at City____________________________ County__________________ State___________ married on_____________________________ at City____________________________ County__________________ State___________
3. The said____________________________ was the son or daughter of_________________________________________
born on_______________________________ at City____________________________ County__________________ State___________ died on_______________________________ at City____________________________ County__________________ State___________ and ______________________________________________________________ his ( ) wife born on_______________________________ at City____________________________ County__________________ State___________ died on _______________ at City____________________________ County__________________ State___________ married on_____________________________ at City____________________________ County__________________ State___________
4. The said____________________________ was the son or daughter of_________________________________________
born on_______________________________ at City____________________________ County__________________ State___________ died on_______________________________ at City____________________________ County__________________ State___________ and ______________________________________________________________ his ( ) wife born on_______________________________ at City____________________________ County__________________ State___________ died on _______________ at City____________________________ County__________________ State___________ married on_____________________________ at City____________________________ County__________________ State___________
5. The said____________________________ was the son or daughter of_________________________________________
born on_______________________________ at City____________________________ County__________________ State___________ died on_______________________________ at City____________________________ County__________________ State___________ and ______________________________________________________________ his ( ) wife born on_______________________________ at City____________________________ County__________________ State___________ died on _______________ at City____________________________ County__________________ State___________ married on_____________________________ at City____________________________ County__________________ State___________
6.The said____________________________ was the son or daughter of_________________________________________
born on_______________________________ at City____________________________ County__________________ State___________ died on_______________________________ at City____________________________ County__________________ State___________ and ______________________________________________________________ his ( ) wife born on_______________________________ at City____________________________ County__________________ State___________ died on _______________ at City____________________________ County__________________ State___________ married on_____________________________ at City____________________________ County__________________ State___________
7. The said____________________________ was the son or daughter of_________________________________________
born on_______________________________ at City____________________________ County__________________ State___________ died on_______________________________ at City____________________________ County__________________ State___________ and ______________________________________________________________ his ( ) wife born on_______________________________ at City____________________________ County__________________ State___________ died on _______________ at City____________________________ County__________________ State___________ married on_____________________________ at City____________________________ County__________________ State___________
8.The said____________________________ was the son or daughter of_________________________________________
born on_______________________________ at City____________________________ County__________________ State___________ died on_______________________________ at City____________________________ County__________________ State___________ and ______________________________________________________________ his ( ) wife born on_______________________________ at City____________________________ County__________________ State___________ died on _______________ at City____________________________ County__________________ State___________ married on_____________________________ at City____________________________ County__________________ State___________