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Lake Township Historical Society
Application for Membership
(To become a member, print this form, fill it out and mail it in.)


Name:  ___________________________________________________________________

Street Address/P.O. Box:  ____________________________________________________

City:  _____________________________________  State:  _________________________

Zip Code:  _________________    E-mail Address:  ________________________________

Home Phone:  (_____)_________________    Business Phone:  (_____)________________

Are you a resident of Hartville or Lake Township?   Yes ____   No ____

Membership Types for Individuals (per year) - Please check one:

_____  $5  Student (under age 18)

_____  $100  Sustaining

_____  $10  Individual

_____  $250  Contributing

_____  $20  Family

_____  $500  Donor 

_____  $50  Patron

 

Life Memberships are available for a one time contribution of $1000

Memberships for Organizations and Businesses (per year) - Please check one:

_____  $25  Non-profit & Civic organizations

_____  $100  Business Sustaining

_____  $50  Business Patron

_____  $250  Business Contributing

 

_____  $500  Business Donor


              I would like information on volunteering   Yes      No   (Circle Preference)

 

Please mail your dues to:

Lake Township Historical Society
P.O. Box 482
Uniontown, Ohio 44685

Thank You For Your Support!


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