| Print this application, then check the appropriate membership information and send it with a check made payable to The Historical Society of Schuylkill County.
The Historical Society of Schuylkill County
P.O. Box 1356
Pottsville, PA 17901
(Membership starts the month that you become a member and runs for twelve (12) months.)
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| _____ Individual - $25.00 | _____ Patron - $100.00 |
| _____ Student - $10.00 | _____ Benefactor - $250.00 |
| _____ Family - $40.00 | _____ Business - $250.00 |
| _____ Contributing - $50.00 | _____ Life - $500.00 |
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| Name __________________________________________________ |
| Address ________________________________________________ |
| City _________________________ State _____ Zip Code __________ |
| E-mail ___________________________________ |
| Telephone ________________________________ |
| Amount Enclosed $_______________ Date: _______________ |
