Please print, complete and return the bottom portion of this form with your payment.
Membership Dues
select one membership level
Student (17 & under) $5.00
Individual $15.00
Couple $20.00
Family $25.00
Sponsor $50.00
Preservationist $100.00
Conservator $250.00
Historian $500.00
Total Amount enclosed _______
Name: __________________________________________
Street: ___________________________________
City: __________________ State ______ Zip ___
Phone number: ______________________
"yes" _____ I will serve as a tour guide at a museum.
"yes" _____ I will volunteer my time for preservation efforts.
Make checks payable to:
Washington Co. Historical Soc. Inc.
P.O. Box 924
Washington, Ia 52353
