Membership Application

Type of Membership (please circle):

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

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

Institutional $30.00 per year

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.