SHA/DCHS Membership Application
Name(s): _____________________________________________________
Additional family member's names: _______________________________
Address: ______________________________________________________
City, State and Zip Code ___________________________________________
Phone
Number ___________________________ E-Mail
___________________
1. Select a Dunn County Historical Society membership category:
[ ] Individual -- $15
[ ] Family -- $20
[ ] Senior -- $10
[ ] Senior Couple -- $15
[ ] Supporting -- $50
[ ] Sustaining -- $100
[ ] Patron -- $250
[ ] Life -- $1,000
2. Add $10 for Stout Historical Association Membership -- $10
3. Additional contribution for Stout Historical Association: -- $ ____________
4.
Total Contribution Enclosed -- $ ____________
(Make checks payable to Dunn County Historical Society)
[ ] Contact me to discuss a gift to the Stout Historical Association.
[ ] Contact me to discuss including the Stout Historical Association in my will or estate plans
Print out this form, fill it out and send your tax deductible contribution to:
Dunn County Historical Society
PO Box 437
Menomonie, WI 54751