Name:
_____________________________________________
Address:
___________________________________________
City, State Zip
_______________________________________
Phone:
_____________________________________________ E-mail
address _______________________________________
Please check your choice:
_____ $20 Individual
_____ $30 Family
_____ $10 Student/Senior
$75 Sponsor
_____ Private
_____ Business
_____ $100 Patron
_____ $500 Benefactor
Enclosed is my check in the amount of $ _______payable to:
The Eureka Heritage Society
PO Box 1354
Eureka, CA 95502
Member Status:
______ New Member
______ Renewal
______ Increase my level of support
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