Please print this form, complete, enclose cheque and mail:
Individual Name or Organization Contact ________________________________________
Position / title, where applicable ____________________________________________
Mailing Address __________________________________________________________
__________________________________________________________
City / Town ________________________________ Postal Code ___________________
Phone (_____) ________________________ Fax (_____) _________________________
Email Address________________________@ __________________________________
Membership Fee Enclosed: Please circle one:
Senior member: $15.00
Individual Membership: $20.00
School / Student: $15.00
Donation: (tax receipt available) ________
Total amount enclosed: __________
Please make cheque payable to: The London and Middlesex Historical
Society.
Mail to:
The London and Middlesex Historical Society,
Box 303, Station B, London, Ontario. N6A 4W1
The London and Middlesex Historical Society