APPLICATION FOR MEMBERSHIP

PRINT & MAIL APPLICATION TO:

Robert J. Kuether
1080 5th Ave.
Steelton, PA 17113 		Date:__________________
Our Society year runs from October 1, to September 30th****

     Dear Bob Kuether,
I do hereby apply for membership in THE THEODORE BURR COVERED BRIDGE SOCIETY OF PENNSYLVANIA, INC. Enclosed are my dues for the class membership I have checked below:

(  ) New Membership
(  ) Renewing Membership
(  ) Individual $15.00 ($16.00 Canadian money)
(  ) Business or club $20.00, if you wish your business or listed name; you may,       however, join as an individual
(  ) Married Couple $20.00
(  ) Sustaining individual or Couple  $20.00
(  ) Lifetime  individual $250.00
(  ) Lifetime Married Couple $300.00

NAME:____________________________________________________________
           [If a couple, please include wife's name. Ex. John J. (Mary C.)]

ADDRESS:_________________________________________________________

CITY:_______________________COUNTY_____________STATE___ZIP:_______________ 9 digits

TELEPHONE________________ EMAIL ADDRESS_____________________________

My occupation, business or
profession_______________________________________
My hobbies are:___________________________________

**If you represent a business or club, please identify it by its full name:
__________________________________________________________________

 
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