MEMBERSHIP FORM

Shipshewana Area Historical Society
PO Box 929
Shipshewana, IN 46565

Name:_________________________________________________________________

Business Contact Person: ______________________________________________

Address:_______________________________________________________________

City: _____________________________________ State: __________ Zip:________

Phone: __________________________________ Cell: ________________________

Email address: ________________________________________________________

Please check one (1) that applies
________ Annual Membership                                                     $   10.00

________ Couple Annual Membership                                       $   20.00
________ Business or Corporation Annual Membership         $ 100.00
________ Lifetime Membership                                                   $ 100.00
________ Bronze Annual Membership*                                      $ 200.00
   *Membership includes recognition in the SAHS Newsletter*
________ Silver Annual Membership*                                        $ 500.00
*Membership includes recognition in the SAHS Newsletter & two (2) Annual Dinner Tickets*

________ Gold Annual Membership*                                          $1000.00
*Membership includes recognition in the SAHS Newsletter & four (4) Annual Dinner Tickets*

*All Memberships receive the SAHS Monthly Newsletter*