Membership Application



Date:   _______________________

[  ] New        [  ] Renewal

Name:  ____________________________________________________________

Spouse:  __________________________________________________________

Address:  _________________________________________________________

City/State/Zip:  __________________________________________________

Email:  ___________________________________________________________

Phone:  _________________________   County:  ______________________


Signature:  _______________________________________________________

Received by:  _____________________________________________________

Please complete form and return with membership dues of $10.00 to the

Iron County Historical Society
P. O. Box 183
Ironton, MO 63650

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