USE THIS MEMBERSHIP FORM TO RENEW OR JOIN FOR THE FIRST TIME!

 

Please complete the form and return it to the Clay Township Historical Society, 8207 Arlington Road, Brookville, Ohio 45309

 

Please indicate if this is a NEW MEMBERSHIP _____  or a RENEWAL _____.

 

Membership Category desired:  (Check One)

_____  $5.00/yr. Individual _____  $10.00/yr. - Family
_____  $100.00 - Individual Lifetime
               (One-time payment)		 _____  $150.00/yr. Corporate
_____  Donation (optional) at any time  

Membership year runs from January through December.

NAME(S)  
STREET & P.O. BOX  
CITY   STATE     ZIP CODE  
PHONE NUMBER    
DUES ENCLOSED   DONATION   TOTAL  


 
Thank you for your support!

2003