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Name __________________________________

Please Check below
Address ________________________________ New Member? _____________
State & Zip Code _________________________ Renewal? ___________________
Phone Number ___________________________ Membership Class _________________________
E-mail address____________________________ Date _______________________
Choose one of the following classes of membership. Amount Paid $__________________
Class of Membership Annual Dues
Member $10.00
Sustaining Member $25.00
Benefactor Member $100.00
Life Member $500.00
Student Member $5.00

Please make checks payable to: The Surry County, Virginia, Historical Society

and mail to P. 0. Box 262, Surry, Virginia 23883.

You can print this application form with the Print command in your web browser's File menu. Look in the upper left corner of your browser screen in the "File" menu for the "Print" command.
We are also happy to receive your application written by hand on a piece of paper!

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Page revised 16 October 2006. © Surry County, Virginia, Historical Society and Museums, Inc.