Membership Application
Date ________________________________________________
Name _______________________________________________
Address _____________________________________________
City ________________________________________________
State ___________________Zip ____________________
Phone (optional) ____________________________________
Email (optional) _____________________________________
Circle Catagory: Amount:
Senior Citizen------------------$12.
Individual------------------------$20.
Family----------------------------$40.
Business-------------------------$45.
Sponsor--------------------------$50.
Patron----------------------------$75.
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
