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Membership Application

Please print and complete this application with the following information and mail it with your check for dues (payable to The Brevard Genealogical Society, Inc.) to:

The Brevard Genealogical Society, Inc.
P.O. Box 1123
Cocoa, FL 32923-1123

Annual membership dues are $20.00 per person and $25.00 per couple. Dues are payable in December and effective for one calendar year. A member is considered delinquent if the dues are not paid by the February meeting of the new year.

Name: ____________________ Spouse's Name: ________________________

Address: ________________________________________________________

City: ____________________________  State: ______  Zip: _______________

Home Phone: ______________ E-mail: _______________________________

Summer Address (if applicable):________________________________________

Summer Phone:_________ Use summer address from ________ through __________

I understand that my name, address, phone and email address will be printed in the Brevard Genealogical Society Annual Membership list which is available to members. Email addresses will be used for the private Society Announcement List.  

I can subscribe or unsubscribe from the public list at:

Signed X _________________________________________ Date: ____________

Spouse X ________________________________________  Date: ____________

Where did you hear about us?______________________________________________________

Form BGS-2 (Rev. 5/05)

  Original material Copyright © 1999-2005 Brevard Genealogical Society, Inc