Name:________________________________________________________________________

Address:_______________________________________________________________________

City, State, Zip Code:_____________________________________________________________

E-mail address:_________________________________________________________________

Telephone number:_____________________________________________________________

FAX number:___________________________________________________________________

Please check the following as appropriate:

_____ New Member ($15.00)

_____ Renewal ($15.00)

_____ Surname & Place Name Lists enclosed (click here for instructions on completing this)

_____ Four-generation pedigree chart enclosed

_____ Please include a copy of the Society's Constitution in my new member packet

Gift memberships only:

Which Dubuque County townships, towns, cemeteries, schools, churches, and so forth are the focus of your research? (This information will be helpful as the Newsletter Editor selects future Newsletter articles.)     Which genealogical references do you recommend that the Society add to its collection?     Are there any genealogies or histories from the places where your ancestors lived (before migrating to the Dubuque County area) that you would recommend the Society add to its collection? (These references could be from foreign countries and in other languages.)

Make check (in U.S. dollars only) payable to and mail to:

Dubuque County-Key City Genealogical Society, P.O. Box 13, Dubuque, IA 52004-0013

For office use. Date received:____________     Amount received:_____________