Membership Form

Name_____________________________________________________________________________________________

Address___________________________________________________________________________________________

City__________________________________________________________Township____________________________

State__________________________________________________________Zip_________________________________

Phone________________________________ New_______ Renewal_______

$100 Life membership________________ $15 Family____________________

$10 Single adult______________________ $2 Students (under 18)__________

$5 Seniors (65 and over)_________ $5 Student (18 and over)________

______________Member/Donor (Double the membership rate)

Total amount enclosed $________________________

Print form and return to:

DuBois Area Historical Society, Inc.

P.O. Box 401, DuBois, PA. 15801

Make checks payable to the DuBois Area Historical Society, Inc.

The DuBois Area Historical Society is a 501(c)3 organization.