South County Historical Society Membership Form

Please provide the following contact information:

Name
Organization if applicable
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail

Choose one of the following Memberships:

Individual  -  $20.00
Couple  -   $35.00
Family with Children under 18  -   $40.00
Sustaining (Individual)  -  $100.00
Patron-Business-Individual or Organization  -  $200.00
Life (Individual)  -  $500.00
Corporate Platinum   -  $3,000.00
Corporate Gold  -  $2,000.00
Corporate Silver  -  $1,000.00

Choose one of the following payment options:

Check
Paypal