Membership Form

Picton & District Historical
and Family History Society Inc. MEMBERSHIP FORM

If you would like to join our Society, please print this page, fill in the form, and mail it with your cheque to: Picton & District Historical and Family History Society Inc, PO Box 64, Picton NSW 2571

APPLICATION FOR MEMBERSHIP
Mr, Mrs, Ms, Miss, Dr
First Name	:	Last Name	:
Street Address:
Town	:	Post Code	:
Phone	:	Fax	:
Email:
Signature	:	Date	:
Please indicate here if you are researching a particular family, locality, or building: ...................................................................................................................... ...................................................................................................................... ...................................................................................................................... ......................................................................................................................
Fees - (please tick which membership is applicable)
Single:	$20.00	Family:	$25.00
Pensioner:	$15.00	Student:	$15.00

Last updated 17/6/07

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