| Moultonborough Historical Society, INC | ||
| Organized in 1958 : Incorporated - September 26, 1994 501(c) (3) Non-Profit Corporation | ||
| P.O. Box 659 | ||
| Moultonborough : NH 03254 | ||
| Renewal or New Membership 2012 | ||
| Please check the 1 Year (or Life) Membership for 2012 you wish, for the amount of money you have enclosed. | ||
| ____ STUDENT Membership (Full-Time Student 26 years of age or under) $2.00 | ||
| ____ Individual Membership $8.00 | ||
| ____ Family Membership $15.00 | ||
| ____ BRONZE Individual/Family Membership $25.00 | ||
| ____ SILVER Individual/Family Membership $75.00 | ||
| ____ GOLD Individual/Family Membership $100.00 | ||
| Please PRINT and complete the form below and mail in with your payment. Thank you! | ||
Last Name
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First Member First Name |
First
Member MI |
Mailing Address
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Second Member First Name |
Second Member MI |
Town
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Comments or list
names of other family members � use back of form for more room |
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State
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Zip Code
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Email Address |
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| Mail to: | ||
| Fran Vincent | ||
| c/o MHS Membership Chairman | Make Checks Payable to: Moultonborough Historical Society | |
| P.O. Box 1148 | ||
| Center Harbor, NH 03226 | ||