 |
|
|
|
|
|
Newark-Arcadia
Historical Society
P.O. Box 289, Newark, New York 14513
MEMBERSHIP FORM
Print out this form and mail to the address listed
below
| Please check membership level desired: | |||
| ( ) | Individual | $15.00 | |
| ( ) | Senior Citizen Couple |
18.00 | age 62 or over |
| ( ) | Senior Citizen | 10.00 | age 62 or over |
| ( ) | Family | 25.00 | 3 or more living together |
| ( ) | Life | 300.00 | |
| ( ) | Sustaining | 50.00 | and up |
| ( ) | Business | 50.00 | and up |
Name _______________________________ Address _____________________________ _____________________________ Telephone______________ Date _________ In Memory of: ________________________ _____________________________________ In Honor of: __________________________ |
Amount Enclosed: $ _______ Roof Fund $ _______ Building Fund $ _______ Operational Fund $ _______ Endowment Fund |
| Please make checks payable to: Newark-Arcadia Historical Society PO Box 289 Newark, NY 14513-0289 |
Rev 2/04 Date ________ Treasurer Date ________ Membership records