Membership Form

MADISON COUNTY HISTORICAL SOCIETY, INC.

P.O. Box 397

Richmond, KY  40476-0397

 

MEMBERSHIP & RENEWALS

All Renewals due in January

 

STUDENT(elementary-college)     $5.00                          _________

SINGLE                                            $25.00                          _________

FAMILY                                            $35.00                          _________

PATRON                                           $50.00                          _________

BENEFACTOR                               $100.00                           _________

BUSINESS OR ORGANIZATION      $50.00                         _________

Additional Contribution to the MCHS                              _________

                                                          TOTAL----------------- $_________

Please make check payable to the

Madison County Historical Society

 

NAME(S):  _______________________________________  DATE:  _______________________

 

ADDRESS:  _____________________________________________________________________

 

CITY:  ________________________________________  STATE:  ______  ZIP:  _______________

 

PHONE NUMBER:  ______________________   EMAIL:  _________________________________

Please include your email address as it is our primary method to contact members!

 

For MCHS use only:  Date Rec’d:______________  Pay Amt: $__________  By:____  List Updated:  ______________

 

Notes: