MEMBERSHIP FORM

LINCOLNVILLE HISTORICAL SOCIETY

Please complete this form and mail to:

Lincolnville Historical Society

P. O. Box 204

Lincolnville, ME 04849

NAME (s) _______________________________________________________________________________________________________

                    ______________________________________________________________________________________________________

CITY/STATE/ZIP______________________________________________________________________________________________

PHONE__________________________________________________________________________________________________________

EMAIL ADDRESS_______________________________________________________________________________________________

                                                  (to receive program and membership information)

ANNUAL MEMBERSHIP

Single member: $5 ______                                           Couple/Family: $10______

Friend: $25______                                                            Lifetime: $100 ________

Additional donation: $ ______________________

Check Enclosed________

Credit Card Information:

MC____Visa____ # ___________________________________________________________Exp. Date____________

Name as it appears on card ______________________________________________

                                                (please print)

Signature __________________________________________________________________

Thank you!