(Please check membership level desired)

1. ( ) Family / Individual $ 15.00

2. ( ) Senior(age 62+) - Family / Individual $ 12.00

3. ( ) Student (Thru College) $ 2.00

4. ( ) Patron Level $ 50.00 +

5. ( ) Corporate Level $ 100.00 +

6. ( ) Benefactor / Memorial $ 1000.00 +

PLEASE PRINT

Name(s): _____________________________________

Address: _____________________________________

City or Town: _________________________________ Zip ________

Telephone: ____________________________

Email Address: _________________________

Amount Enclosed $ ________________ Date: ________________

Make checks payable to the  Galen Historical Society   and mail to:

If this is a Gift Membership, please select the level of membership desired and fill in the individual's name and contact information.

   Gift Membership from: ___________________________________________

If this is a Donation, please fill in your name and contact information above.

   Donation ( ) In Honor of: ( ) In Memory of: ___________________________________________

   Do you require a receipt for your donation? ( ) No ( ) Yes