MEMBERSHIP FORM
Please fill in the boxes on this form appropriately, then print
it to the address below.
DATE: PHONE:
NAME
ADDRESS 1:
ADDRESS 2:
CITY: STATE ZIP
IS THIS A
PLEASE CHECK YOUR CHOICES:
Individual
Member ($15.00)
Family
Membership ($25.00)
Contributing
Member ($30.00)
Student
(18 yrs & under) ($8.00)
Sustaining
Member or
Corporate
Member ($150.00)
SPECIAL INTEREST SECTIONS
GENEALOGY
Civil
War
Museum
Archaeology
For Family Memberships, please list your children here:
Name: Age:
Name: Age:
Name: Age:
Name: Age:
Name: Age:
Membership year is January 1 to December 31:
Make your Check to: KOSCIUSKO COUNTY HISTORICAL SOCIETY |