| ( ) Senior Citizen | $15.00 | ( ) Historian | $100.00 |
| ( ) Individual | $20.00 | ( ) Archivist | $500.00 |
| ( ) Family | $30.00 | ( ) Benefactor | $1,000.00 |
| ( ) Curator | $50.00 |
In addition to my membership, I'd like to contribute the amount of $______________ to the Needham Historical Society to be used for _______________________.
Dues are for the calendar year. Please indicate if this is a new _____ or a renewal _____ membership.
| Your Name | _____________________________________________ |
| Your Address | _____________________________________________ |
| City, State, Zip | _____________________________________________ |
| Telephone | _____________________________________________ |
( ) Check here if your employer has a matching funds program.
Please print and mail with your check to:
