Memberships are from Jan 1-Dec 31, 20____

NAME:____________________________________________________ STREET:__________________________________________________ CITY:_____________________STATE:__________ ZIP:____________ PHONE: ______________________ e-mail: ______________________ __Individual Life Membership_______________________$ 150.00 __Family Life Membership_________________________ $ 175.00 __Charter Individual Renewal (joined during 1983)_______ $ 12.00 __Charter Family Renewal (joined during 1983)__________$ 13.00 NEW____Individual $ 20.00___ Family $ 20.00___ RENEWAL__ DONATION_______ Surnames of interest in Henry County__________________________________________________________

THANK YOU FOR YOUR SUPPORT

Mail completed form along with your check to:

Henry County Genealogical Society
P.O. Box 346
Kewanee, Illinois 61443

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