MASTER and
VISA acceptedPlease print the form, complete and send check or money order to:
Anoka County Historical Society
2135 Third Avenue North
Anoka, MN 55303-2421
For more information email: theresa@ac-hs.org
MASTER and
VISA accepted
MEMBERSHIP
Date: ___________________
Name(s):________________________________________________
Address: ________________________________________________
City, State & Zip:
_________________________________________
Home Phone: (
_________ ) ________________________________
Work Phone: (
__________ ) _______________________________
Email (Optional) __________________________________________
Special Interests and Skills:
_________________________________
_______________________________________________________
If you are gone for an extended period during the year, please provide your “other” address, if available,” with the month of departure and month of return. Departure month: ____________ Return month: _______________
Other
address:_________________________________________________
City,
State & Zip: _______________________________________________
____ Family $25.00
____ Individual
$ 15.00
____ Senior Citizen (62+) $ 7.00
____ Student (6-17) $ 7.00
MEMBERSHIP DUES
$
_____________
To further support ACHS in preserving Anoka County history,
ENCLOSED IS A DONATION OF:
$ _____________
TOTAL AMOUNT ENCLOSED:
$ ____________
Thank you for your
support!
Method of Payment:
Check enclosed payable to The Anoka County Historical Society _____
Or charge to: ___MasterCard ____Visa
Account#: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration Date: __ __ Mo. - __ __ Yr.
Signature: ______________________________________________________________
If you would prefer that we NOT share your name with other like-minded organizations, please check here: ___________