MEMBERSHIP  APPLICATION

 

 

MARISSA HISTORICAL AND GENEALOGICAL SOCIETY

P.O. Box 245

Marissa, IL 62257-0245

U.S.A.

 

 

Date: ____________________

 

 

NAME:

__________________________________________________________________________

 

MR.  _____; MRS.  _____; MR. & MRS.  _____; SPECIFY TILE  __________________

 

ADDRESS:

______________________________________________________________________

 

CITY:

___________________________________________________________________________

 

STATE:  ____________________  ZIP CODE:  ___ ___ ___ ___ ___ + ___ ___ ___ ___

 

COUNTRY:  _____________________________________

 

PHONE NUMBER:  _____________________________________________

 

E-MAIL ADDRESS:  __________________________________________________

 

RESEARCHING:  _______________________________________________________________

 

 

Type of Membership

 

                                         _____ Individual and Family - $25.00 (One Quarterly)

                                         _____ Student  - $10.00 With Quarterly

                                         _____ Patron Member - $35.00 (1st Time Member)

                                      

                                     

 

Special Tax Deductible Equipment Fund Donation: $__________________

 

If you desire a Membership Card, please send an SASE with your Dues along with this Application Form.

 

 

Please make checks payable to: Marissa Historical and Genealogical Society