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2. Print this form, fill it out and mail it to:
   Bob Furst
   245 Bluebird Drive
   Colchester, VT 05446
   
   "Thank you for your interest in joining our Historical Society"
   --Nancy Burke, President.
4. Date
   Date
6. First Name
7. Last Name
9. Address1
11. City
12. State
13. Zip
15. Home/Cell Phone
17. Email
19. Please indicate any interests you may have in serving on the committees below:

    1. Audit
    2. Book Inventory
    3. Building
    4. Landscaping

    1. Library
    2. Membership
    3. Nominating
    4. Phone

    1. Program
    2. Refreshment
    3. Schoolhouse Museum
    4. Website
21. Dues Options:

    1. Single Annual Membership - $5
    2. Family Annual Membership - $10
    3. Single Lifetime Membership - $100
Leave This Blank:


22. Print Only

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