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MAIL MEMBERSHIP FORM WITH PAYMENT TO:

Burlington Historical Society
232 N. Perkins Blvd.
Burlington, Wisconsin 53105

(Please Print)

DATE: ______________

NAME : __________________________________________|___________________

  (Last, First Middle) | (Maiden name)

ADDRESS: ____________________________________________________________

CITY__________________________________STATE________ZIP_________________

TELEPHONE: (____)_____ ___________ NEW [__] RENEWAL [__]

AREAS OF INTEREST (OR RESEARCH YOU WOULD LIKE TO KNOW MORE ABOUT):

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

E-MAIL ADDRESS_________________________ HOME PAGE URL __________________________

YEARLY MEMBERSHIP DUES:

[__] GENERAL MEMBERSHIP - $10.00

[__] CONTINUING MEMBERSHIP - $25.00

[__] I'D LIKE TO MAKE AN EXTRA DONATION (Thank You !!): ________________

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Burlington Historical Society
Last modified: 4/17/2013