Bronzeville/Black Chicagoan Historical Society Membership Application Form Please print or type Name__________________________
Address_______________________
City ____________State ____ Zip Code ___________ Telephone Number _____________________
Fax__________
Your E-mail address: ______________________________
Type of membership: ______ Individual $18.00 ______ Contributing $30.00 ______ Family - $21.00 ______ Life Member $250.00 (Canada and outside the U.S. please add $3.00 in U.S. funds to the above amountAdd a Contribution to the National Archives Fund ($1.00 suggested) Submit Bronzeville People, Places or Events you would like to have noted in the historical society newsletter.
Make check payable to : Bronzeville
Historical Society P.O. Box 53345
Chicago, IL 60653-0345
E-mail: [email protected]
www.bronzevillehistoricalsociety.com 773 291-9114 phone 773 291-9115 fax
Date: ______________ Signature: _____________________
