Membership Application Form

                                                            Name:__________________________________________________

Street Address:_________________________________________________

City, State & Zip Code:____________________________________________

Email Address:___________________________________________

Phone Number:___________________________________________

*If this is a Gift Membership, please print out an additional form with the recipients information.  Please let us know if you would like us to send an acknowledgement of this gift to the recipient.

Categories:  Please indicate the category and make checks payable to:

Colchester Historical Society

Individual Membership - $5.00_________________

Genealogy Membership- $35.00_______________

             Surname:_______________________________________

__________________________________________________________________________

Building Fund Contribution:  Please consider giving an additional contribution to our Building Fund.  Our future goal is the purchase of a building to preserve our local history collection, provide research space and also museum space to exhibit our artifacts collection.

Building Fund Contribution:   $_________________

Memorial Gift:   $___________________  Please accept this gift in memory of:

_________________________________________________________________________

Please mail your Membership Application to:

     Colchester Historical Society, Box 112, Downsville, New York 13755