I would like to become a member of

Enclosed is $ ________
for membership in the category indicated:

____ Single Life Membership $ 250   ____ Family $25
____ Adult $15   ____ Student $5   ____ Corporate $100
____ Senior $12   ____ Senior Family $20

Members receive the Society's newsletter, published five times a year.

NAME: _________________________________________

TELEPHONE: __________________________________

ADDRESS: ______________________________________

CITY: __________________________________________

STATE: ____________________ ZIP: _______________

Make checks payable and mail with this completed form to:

Auglaize County Historical Society
223 South Main Street
St. Marys, Ohio 45885

Memberships are tax deductible to the extent allowed by law.