ANNUAL MEMBERSHIP  APPLICATION

TYPE OF MEMBERSHIP: 

 ___SINGLE  $10.00    ___HOUSEHOLD  $20.00    ___BUSINESS   $50.00    

Name___________________________________________________         Date_____________

Address  _________________________________________________      

City________________________________________State______Zip___________

Phone_______________________     Cell_______________________

Email___________________________________________________

___HOUSEHOLD

Fill in information above, plus names and e-mails of additional household members: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___BUSINESS/ORGANIZATION

Name of Business/Organization: ___________________________________________________

Contact Name: __________________________________________

Address________________________________________________

_______________________________________________________

_______________________________________________________

Phone_______________________     Cell______________________

Email___________________________________________________

Website:________________________________________________

Annual Memberships: Individual $10.00;   Household $20.00;   Business/Organization $50.00

Please return form with check made out to: Whitehall Borough Historical Society

Mail to John Wotus at P.O. Box 10911, Pittsburgh PA 15236