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Moravian Heritage Society Membership Application/Gift Membership

NAME: _____________________________________________________Date:________________

ADDRESS:____________________________________    CITY/STATE:_____________________

ZIP (use 9 digit):_____________________________           PHONE:_________________________
Ancestor's Surname Birth Date Village/County Country Where 1st Settled in America
1._______________________________________________________________________________
2._______________________________________________________________________________
3._______________________________________________________________________________
4._______________________________________________________________________________
Join: Regular Member Patron Member Sponsor Member
__ $17/one year __ $23/one year __ $50 Silver Sponsor
__ $29/two years __ $39/two years __ $100 Gold Sponsor
__add $2 for Canadian and overseas postage

Send to: Moravian Heritage Society 6N432 Oakwood Drive Saint Charles, IL 60174