MEMBERSHIP FORM

Name: _________________________________________________________

Address: _________________________________________________________

City/State/Zip: _________________________________________________________

Phone: _________________________________________________________

Email: (optional) _____________________________________________________

Single Membership: Annual - $10.00 Life - $100.00

Family Membership: Annual - 15.00 Life - 160.00

Business Membership: Annual - 100.00

Non-Profit Organizations: Annual - 25.00

Date: ______________________________________

_______ Renewal            _________ New

Please make checks payable to Largo Area Historical Society and mail along with this form to:

Marilyn Short
Largo Area Historical Society
1260 Leona Dr.
Largo, FL 33770