Membership Application
Date ________________________________________________
Name _______________________________________________
Address _____________________________________________
City ________________________________________________
State ___________________Zip ____________________
Phone (optional) ____________________________________
Email (optional) _____________________________________
Circle Catagory: Amount:
Senior Citizen------------------$10.
Student----------------------------$10.
Individual------------------------$15.
Family----------------------------$30.
Business-------------------------$35.
Sponsor--------------------------$40.
Patron----------------------------$50.
Life (one time payment)---$150.
Benefactor--------------------$200.+
Print form and send with check or money order to:
Historical Association of South Jefferson
29 E. Church St.
Adams, NY 13605
