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NAME: (lAST) __________________       (First) ___________________

ADDRESS: _________________________________

CITY________________STATE_____ ZIP________

MEMBERSHIP DUES

		Individual / $5.00
		Life Member / $50.00
		Donation $________

Thank you for your donation. The OBHS is a not for profit organization.

Copy and Mail to:
The OLD BRUTUS HISTORICAL SOCIETY
P.O. Box 516
Weedsport, NY 13166

We need your participation!
If you are a local resident, would you be interested in becoming a museum volunteer?

		YES
		NO