ALGER-SULLIVAN HISTORICAL SOCIETY
 P.O. Box 1002
Century, Florida 32535
http://algersullivan.org


Name(s) _____________________________________________ Date ________________

Address ____________________________________________________________

City ______________________________________ State ______ Zip _________________

Telephone _____________________

Email Address _________________________________

Dues $5.00 per person                                  _______________

Lifetime Dues $100.00 per person               _______________

Donation                                                          _______________

Donation for Old 100                                      _______________


TOTAL ENCLOSED                                      _______________

(Please make checks payable to ALGER-SULLIVAN HISTORICAL SOCIETY or ASHS)


Please complete this form and bring it with you to the next meeting
or please mail the form with your check.

Note that names, addresses, email addresses, or any other personal information we have of our members will not be used in any way other than for the use of the Alger-Sullivan Historical Society or its membership. Your information will not be sold or distributed in any way without your prior knowledge and consent. If you have any questions or concerns regarding this statement, please let us know.




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This page last modified on Friday, February 18, 2005