BRONZEVILLE / BLACK CHICAGOAN HISTORICAL SOCIETY
MEMBERSHIP APPLICATION
Name of Individual or organization:
Your home or mailing Street
address:
City/State / Zip
Organization /Site Address
_City State ______ Zip
Tel: Cell phone:
Web site:
E-mail address:
Proposed organizational representative to Bronzeville Historical Society
Representative’s title, street address, telephone, fax and e-mail address if
different than above:
Type of membership : Individual ($18.00) Family ($21.00)
Contributing ($30.00) Life Member ($250.00) Senior/Student ($10.00)
Corporate Sponsor ($10,000.00 or more)
DATE____________________ Membership Year:
Complete this application and return by U.S. Mails
MAKE CHECK PAYABLE TO
BRONZEVILLE HISTORICAL SOCIETY
SEND TO:
11431 S. Forrestville Ave.
CHICAGO, IL 60628-5109
E-mail: [email protected]
773 291-9115
www.BronzevilleHistoricalSociety.com
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