Membership / Volunteer Application
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DATE ____/____/____
mm dd yy
NAME (first) ____________________ (mi)_____ (Last) ________________________
ADDRESS _____________________________________________________________
_____________________________________________________________
TELEPHONE (home) (_____)______________________________________________
(other) (_____)______________________________________________
E-MAIL ________________________________________________________________
MEMBERSHIPS |__| Individual $10.00
|__| Family $20.00
|__| Lifetime $200.00
|__| Children (16 & under) $5.00
VOLUNTEER |__| You may call me to help as a volunteer
Make checks payable to: Historical Society of Perry County
Send To: Historical Society of
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