West Lincoln Historical Society Membership Application

Box 797
288 Station Street
Smithville, Ontario, Canada L0R2A0

Be a part of history: share the memories of our past, present and future.

First Name (required)

Last Name (required)

Member Number-for renewals only

Street Address (required)

Mailing Address

City (required)

Province/State (required)
Postal/Zip Code (required)

Country (required)

Telephone Number (required)

Email (required)

Membership Dues:
     Individual - $10.00 per year
     Family (at same address)- $15.00 per year
Date:

RenewalNew Member

Membership Payment
Additional Donation

Total Remittance

Please make cheque or money order payable to: West Lincoln Historical Society

Send to above address

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