APPLICATION FOR MEMBERSHIP

(Effective with 2015-2016 membership)

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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:

(See note below to pay dues through PayPal.)

          (    ) New Membership           (    ) Renewing Membership
----------------------------------------------------------------------------------------------------------
(    ) Individual $15.00
(    ) Group or Club $20.00
(    ) Business $20.00 (if you wish to list your business name; if not, you         may join as an individual)*
(    ) Couple/Family at the same address $20.00
(    ) Sustaining individual or Couple/Family at the same address $20.00
(    ) Lifetime individual $250.00
(    ) Lifetime Couple at the same address $400.00
 
 

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:_______________________________________________________________________________

Tell us how your heard about our Society___________________________________________________________

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

New members and current members may pay their dues through PayPal (does not apply to Lifetime memberships).  Log in to your PayPal account and send your membership dues to: ebridge59@verizon.net. Your dues will be sent to Treasurer Bob Kuether. Please add $1 to your total dues to help offset PayPal fees.

 
   

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