Name:_________________________________________________________Date_____________

                          First                     MI                       Last

Address:__________________________________________________________________

                               Street                                     City                                   St                 Zip

Phone_____________________ E-Mail________________________________________

Type of Membership: Single $12.00 ( ) Family $15.00 ( )

Student $2.00 ( ) Lifetime $150.00 ( )

One Year Membership ( ) Two Years ( ) Three Years ( ) Lifetime ( )

Amount Due $_____________

Make Checks payable to: Medway Area Historical Society

May we have your permission to use your name, address, and E-mail in our Member Directory?

Yes ( ) No ( )

*This directory will carry a notice to be only used by MAHS and not for any other group or business.