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Name:
___________________________________________________________________
Street Address/P.O. Box: ____________________________________________________
City: _____________________________________
State:
_________________________
Zip Code: _________________ E-mail Address:
________________________________
Home Phone: (_____)_________________ Business
Phone: (_____)________________
Are you a resident of Hartville or Lake Township?
Yes ____ No ____
Membership Types for Individuals (per year) - Please check one:
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_____ $5 Student
(under age 18)
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_____ $100 Sustaining
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_____ $10 Individual
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_____ $250 Contributing
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_____ $20 Family
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_____ $500 Donor
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_____ $50 Patron
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Life Memberships are available for a one time
contribution of $1000
Memberships for Organizations and Businesses (per year) - Please check
one:
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_____ $25 Non-profit & Civic
organizations
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_____ $100 Business Sustaining
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_____ $50 Business Patron
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_____ $250 Business Contributing
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_____ $500 Business Donor
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| I would like information on volunteering Yes No (Circle Preference) |
Please mail your dues to:
Lake Township Historical Society
P.O. Box 482
Uniontown, Ohio 44685
Thank
You For Your Support!
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