MEMBERSHIP FORM
Memberships are from Jan 1, 2023-Dec 31, 2023
NAME:____________________________________________________
STREET:__________________________________________________CITY:_____________________STATE:__________ ZIP:____________
PHONE: ______________________ E-Mail: ______________________
__Individual Life Membership_______________________$ 175.00
__Family Life Membership_________________________ $ 175.00__Charter Individual Renewal (joined during 1983)_______ $ 12.00
__Charter Family Renewal (joined during 1983)__________$ 13.00NEW____Individual $ 20.00___ Family $ 20.00___ RENEWAL__ DONATION_______
Surnames of interest in Henry County__________________________________________________________
THANK YOU FOR YOUR SUPPORT