The Trail Blazers Enrollment Form
In support of the important work of Washington County Historical Association, I/we accept this invitation to become a member of The Trailblazers for the year _________ at the following membership level:

[   ] Bronze Circle
($300 or more annually as long as circumstances allow.)

[   ] Silver Circle
($500 or more annually as long as circumstances allow.)

[   ] Gold Circle
($750 or more annually as long as circumstances allow.)

[   ] Platinum Circle
($1,000 or more annually as long as circumstances allow.)

Enclosed is $____________ with the balance to be given as follows within this calendar year:

[   ] Annually _______; Quarterly _______; Monthly ________; Other _______.

[   ] My gift may be matched by ________________.

[   ] You may pay this amount with Visa Card or Master Card.

Card Number: _____________________________    Expiration Date: __________

Signature ___________________________________________________________

Name ______________________________________________________________

Address ____________________________________________________________

City ___________________________ State _____________ ZIP _____________
 

Phone____________________    Today's Date________________

Please make check payable to Washington County Historical Association and mail to Post Office Box 25, Fort Calhoun, Nebraska 68023

Telephone: 402-468-5740 E-Mail: info@newashcohist.org.

All gifts are deductible for tax purposed to the full extent provided by law.