Membership Application

Type of Membership (please circle):

(I) Individual $20.00 per year (F) Family (same address) $25.00 per year

(S) Senior $15.00 per year (SF) Senior Family (same address) $20.00 per year

(I) Institutional $30.00 per year

(B) Business $50.00 per year

Special Gift of Support $___________

Name: ____________________________________________________________________________________

Additional Names: __________________________________________________________________________

Address: __________________________________________________________________________________

State: ______ ZIP Code: ______________ Phone/e-mail: _________________________________________

Questions/Comments:________________________________________________________________________

__________________________________________________________________________________________

Mail this completed form, along with a check payable to Hartford

Historical Society, to the Treasurer at P.O. BOX 547, Hartford, VT 05047.