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Membership Enrollment Form
In support of the work of the Washington County Historical
Association, I/we enclose a check in the amount of
$_____________ for my/our annual membership.
(made
payable to Washington County Historical Association.)
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Trailblazer |
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Platinum
Trailblazer Member |
$1,000 |
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Gold
Trailblazer Member |
$700 |
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Silver
Trailblazer Member |
$500 |
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Bronze
Trailblazer Member |
$300 |
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Associate
Member |
$200 |
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Patron Member |
$150 |
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Sustaining
Member |
$100 |
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Supporting Member |
$50 |
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Individual/Household Member |
$25 |
Name:
_________________________________________________________________________
Card Number: _____________________________________ Expiration
Date: _______ / _______
Signature:
_______________________________________________________________________
Address: _________________________________ City/State/Zip
___________________________
Phone: ___________________________
Email address: ________________________________
Please send
to:
Washington County Historical Association
102 N. 14th Street PO Box 25
Fort Calhoun, Nebraska 68023-0025
Fax to: 402-468-5741
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