MEMBERSHIP TYPE SELECTION

-Place an X on The Type of Membership You Want-

-Then fill in rest of form-

ALL MEMBERSHIP FEES ARE ANNUAL EXCEPT FOR LIFETIME MEMBERSHIP

  BASIC Memberships (Senior=65 or Older)	SUSTAINING Memberships

   Senior-Family (same address) 	$15	   Individual 		$150
   Senior-Individual            	$15	   Family (same address) 	$200
   Individual                   	$20	
   Family (same address)        	$30	

  CONTRIBUTING Membership       		LIFETIME Memberships (one time payment)		  

   Individual        	  		$40	   Individual 		$300	 
   Family                 		$50 	   Family (same address) 	$300
	

  BUSINESS/CORPORATE			$300
    Send Business Card with Application

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 Name of Person Initiating Membership: 
    Membership Name to be on Card:       

    Name for Addressing Mail: 
     

     Residence Address: 
                  City: 
                  State:  (2 Letter Abbreviation)  Zip Code: 

     Mail Address:    

      (if different)  
                  City: 
                  State:  (2 Letter Abbreviation)  Zip Code: 

     Telephone # (wired)    Area Code:  Tel #: 
     Telephone # (wireless) Area Code:  Tel #: 

     E-Mail Address:     

     I would accept Newsletter by Email YES  NO  

 If Selected Membership is Family Type, list names (with last names if different and age

 of children if under 12) of members to be included in membership in blocks below 

 (multiple names separated by commas can be entered in each box (up to 90 characters 

 per box):

 Names(1)      

 Names(2) 

 Names(3)      

 Names(4) 

  YES, I WOULD LIKE TO HELP THE GEORGETOWN HISTORICAL SOCIETY AS A VOLUNTEER: SO CONTACT ME  

	Once you sign up, each member whether signed up as an individual or as 

	part of a family membership will receive a membership card in the mail

	in four to six weeks of our receipt of your application and membership

	payment, but your membership privileges start as soon as we receive

	your application and dues payment.