MEMBERSHIP FORM

______$12.00 Individual

______$17.00 Family

______$27.00 Contributing

______$52.00 Corporate

______$2.00 Student

NAME_________________________________________________________

ADDRESS______________________________________________________

_______________________________________________________________

PHONE___________________________

E-MAIL___________________________

___NEW MEMBER ___RENEWAL

Mail To:

NEW HARTFORD HISTORICAL SOC.
P.O. BOX 238
NEW HARTFORD, NY 13413

TEL. 724-7258