Membership Form

	Name:   Address:   City:   State:   Zip Code:   E-Mail:   Membership Type: Renewal:       New:             Sponsor:     $100.....     Contributing:$ 50.....     Family:      $ 30.....     Single:      $ 20.....     Student:     $  5.....     Donation:    $........ Please print this form, fill it in and mail to the address below.  Thank you!! Mailing Address: Madison County Historical Society P. O. Box 696 Anderson, IN 46015-0696 Historical Interests: (check all that apply)   Local:..... State:..... U.S.A:..... Civil War:..... Genealogy:..... Black History:..... Museum Collection:..... Preservation/Restoration:..... Other:........................