You are cordially invited to become a member of the
Mahanoy and Mahantongo Historical & Preservation Society, Inc.
Please Fill Out This Form, then Print It and Mail It to:
Mahanoy and Mahantongo Historical & Preservation Society, Inc.
P.O. Box 143, Dalmatia, PA 17017
I/We hereby apply for membership in the Mahanoy and Mahantongo Historical & Preservation Society, Inc.  I/We understand that membership covers the calendar year. Memberships received after November 1st extend through the following calendar year. Memberships not renewed by March 1st will be considered expired.

Enclosed please find my membership payment as indicated:

LIFE ($500)
BENEFACTOR ($250/yr.)
SUSTAINING ($100/yr.)
CONTRIBUTING ($50/yr.)
FAMILY ($25/yr.)
INDIVIDUAL ($12/yr.)
STUDENT ($5/yr.)
Any amounts in excess of base membership (Student, Individual or Family) constitute a contribution to MMHPS and may qualify for tax deduction; they also accumulate toward Life Membership.

Date _____/_____/2003

Name :
Address :
City :  State :  Zip :
Phone Number :() 
eMail address :
Please make check payable to: MMHPS, INC.  

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