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Please print out this form, fill it out and return it, with your check, to: 

Ford County Historical Society

Attn: Membership Chair

P.O.Box 115

Paxton, IL   60957-0115

Annual dues are payable September 1st of each year.

Please mark the desired level of membership

____ History Teacher -- Honorary Membership    $ Honorary
____ BASIC Individual, _____ persons, $10.00 each for individuals under the age of 85   $__________
____ LIFE Membership (in one payment) _____ persons, $100.00 each in single lump sum
or in four $25 annual installments
___"May I give EXTRA to help with postage?"   Yes, and Thank You!   $__________
Make your check payable to F.C.H.S. …………………………TOTAL      $__________



My name: _________________________________________________________________ 

My spouse (at same address):  _________________________________________________ 

Street Address:  ____________________________________________________________ 

City, State & Zip code:  _______________________________________________________ 

Phone:  ____________________________  E-mail Address:  _________________________ 

Gift Memberships are always a great idea! 

Fill out the above information with the recipient of the gift in the address area, circle “Gift Membership” above and add your name below.  The recipient will receive a membership card along with a notice of your gift.  For multiple gifts send one check along with a form for each gift membership.

Gift from:  _________________________________________________________