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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: ______________________________________

I wish to pay my membership dues by **

If paying by check/money order, please Print this Form and mail along with your check or money order made payable to Largo Area Historical Society to:

Largo Area Historical Society
6272 – 151st Terrace N.
Clearwater, FL 33760