Membership Application

Dues: 10.00 (July 1, 2003 thru June 30, 2004) -- Includes Historical Society Dues

Please Type or Print

Name: ________________________________ Maiden Name: __________________

Street Address: __________________________________________________________

City: ___________________________________ State: _________________________

Zip Code (Including 4 digit extension): _______________________

Phone Number: (_____________) __________________________

Return completed form and a check or money order for $10.00. Please make all checks payable to the Nemaha County Historical Society. Enclose a SASE if you wish to receive your membership card thru the mail. Address the application to the Nemaha County Historical Society, 6th and Nemaha, Seneca, KS 66538.

June 2003