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                       MEMBERSHIP ENROLLMENT
     
	 
	 
     Mail to:
	 
     CATLIN HISTORICAL SOCIETY	
     P.O. Box 658
     Catlin, Illinois 61817-0658


     Date ______________________

    
	   Name ________________________________________________________________

   
    Address _____________________________________________________________

   
    City ____________________________ State ______________ Zip __________
	 
     Phone (_____) ___________________
	 
     [  ] Youth (under 18)........................................ $  5.00
	 
     [  ] Senior Citizen (over 65)................................ $  8.00
	 
     [  ] Senior Couple (one over 65)............................. $ 12.00
	 
     [  ] Individual ............................................. $ 10.00
	 
     [  ] Family ................................................. $ 15.00
	 
     [  ] Corporate .............................................. $ 50.00
	 
     [  ] LIFE Individual ........................................ $150.00
	 
     [  ] LIFE Family ............................................ $250.00
	 
     Membership year is January 1 to December 31
	 
     Gift contribution ___________________________________________________