Membership Application

    Name _________________________________________

    Address _______________________________________

    City/State ______________________________________

    Zip + 4 ________________

    Area Code/Telephone _________________________

    E-Mail _________________________________________

    Check one:
    ____ Regular Membership.............................................. $ 20.00
    ____ Family Membership................................................ $ 22.00
    (Add $2.00 for each member over two)
    ____ Charter Membership.............................................. $ 12.00
    ____ Student Membership.............................................. $ 10.00
    ____ Contributing Membership...................................... $ 40.00
    ____ Life Membership.................................................... $ 300.00

Plus you may also make a donation to:
____ Stern NARA Gift Fund Donation ........................... $ .
TOTAL ............................................................................. $ .

    Is this a new membership? Y _____ N _____

    Membership year is from January 1 to January 1. You will be receiving a membership card.

In order to receive your quarterlies, we MUST have your entire nine-digit zip code as it is now required for bulk mailing by the U.S. Postal Service. Please notify us of any change of address as soon as possible! Current international postage will be billed if appropriate.

        Remit by check payable to:
        Rock Island County Illinois Genealogical Society
        P.O. Box 3912
        Rock Island Illinois 61204-3912