NAME: _________________________________________________

  ___ New Membership
  ___ Renewal

MAILING ADDRESS:
  Street __________________________________________________
  PO Box ________________________________________________
  City ___________________________________________________
  State _______________________ZIP CODE __________________

PHONE NUMBER (        ) ____________________________
EMAIL ADDRESS __________________________________

Please indicate which membership you are seeking
ANNUAL __________ ($10.00/yr)               LIFE __________($50.00)

PRINT this form, complete and send along with a check payable to:
Maytown Historical Society
PO Box 293                     
Maytown, PA 17550-0293

Thank you for supporting our Society...and its work!