Membership's Application


PIKE COUNTY  GENEALOGY & HISTORICAL SOCIETY
             P. O. Box 224, Waverly, Ohio 45690-0224

Membership for:    2012______2013______2014_______2015________
(check one or more)

Please print or type:

NAME: _________________________________________________

ADDRESS:_______________________________________________

        __________________________(please include 4+zip)

PHONE:(   )_________________  FAX:(   )_________________

E-MAIL:______________________________

Dues:
_________$  10.00  Single Member         _________ Renewal

_________$ 12.00  Family Membership   _______ New Member

(Members will receive four newsletters of Pike County information per year.)
(Dues are due January 1st of each year)

Please send your 5 generation charts, 3" x 5" ancestor cards,
copies of your Bible Records and articles about your Family.

SURNAMES BEING RESEARCHED:__________________________________

____________________________________________________________

Optional:
I hereby give the Pike Co. Genealogical & Historical Society permission
to use in the publications and/or newsletters the following:

                                                  YES ___  NO ___   5 GENERATION CHARTS
                                                  YES ___  NO ___   BIBLE RECORDS
                                                  YES ___  NO ___   CORRESPONDING LETTERS
                                                 YES ___  NO ___   PHONE NUMBERS  YES ___  NO ___  
                                                 YES ___  NO ___   ADDRESSES      YES ___  NO ___ E-MAIL

SIGNATURE:____________________________  DATE_______________

PLEASE PRINT OUT THIS APPLICATION, FILL IN THE APPROPRIATE
SPACES, AND MAIL BOTH THE COMPLETED APPLICATION AND YOUR
REMITTANCE TO:  P.O.Box 224, Waverly, Ohio 45690-0224

Please support the society & keep it in operation!

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