North Santiam Historical Society Membership Form

Membership: ($10 yearly includes four newsletters.  Over age 80, dues optional)

Please provide the following contact information:

Name
Street Address
City
State/Province
Zip/Postal Code
E-mail

I enclose $ for (how many?) members

continuing membership(s)
new membership(s)
honorary member (80 years or older)

Contribution Opportunity

I also want to make a tax-deductible gift to:  (Please indicate amount)

$		Canyon Life Museum
$		the newsletter
$		other (please specify)
$		as needed
$		in honor of