MEMBERSHIP  APPLICATION

MARISSA HISTORICAL AND GENEALOGICAL SOCIETY

P.O. Box 245

Marissa, IL 62257-0245

U.S.A.

Date: ____________________

MR.  _____; MRS.  _____; MR. & MRS.  _____; SPECIFY TILE  __________________

STATE:  ____________________  ZIP CODE:  ___ ___ ___ ___ ___ + ___ ___ ___ ___

COUNTRY:  _____________________________________

PHONE NUMBER:  _____________________________________________

E-MAIL ADDRESS:  __________________________________________________

RESEARCHING:  _______________________________________________________________

Type of Membership

                                         _____ Individual and Family - $20.00 (One Quarterly)

                                         _____ Patron Member - $25.00 (1st Time Member)

                                         _____ Patron Member - $20.00 (Renewal Member)

                                         _____ Life Membership (Individual) - $150.00

                                         _____ Life Membership (Husband and Wife) - $200.00

Special Tax Deductible Equipment Fund Donation: $__________________

If you desire a Membership Card, please send an SASE with your Dues along with this Application Form.

Please make checks payable to: Marissa Historical and Genealogical Society