Memberships Form

Name:______________________________________	Date:___________________
Address:_____________________________________
City:________________________________________	State:_________________	Zip code:______________
Business Phone:_______________________________	Home Phone:_________________________
E-mail:______________________________________

Circle One:

Individual $10	Family $17.50	Corporate $25	Sponsor $50	Benefactor $100

Please send completed card with check to:	Terrell County Historic Preservation Society
	P.O. Box 63
	Dawson, GA 39842