Registration/Membership Form

Event- _____________________________________

Dates-                                                   Amount Enclosed-                                                    

Event- _____________________________________

Dates-                                                   Amount Enclosed-                                                    

Event- _____________________________________

Dates-                                                   Amount Enclosed-                                                    

             New                                  Renewal

              Junior ($5.00)                      Individual ($25.00)                       Family ($35.00)

              Senior ($20.00)                  Sustaining ($45.00)                  Patron ($75.00)

              Institutional ($75.00)                  Business Sustaining ($125.00)   

              Corporate Sustaining ($275.00)                        Life ($500.00)                      

 Amount Enclosed-                                                       

Name-                                                                                                                                                            

Address-                                                                                                                                                        

Phone-                                                                 E-mail-                                                                             

Total Enclosed-                                                                        

Return with payment to:

Jefferson County Historical Society

228 Washington St.

Watertown, NY  13601