Individual Membership Form

Personal Information

Full Name:	____________________________________________________
Address:	____________________________________________________
	____________________________________________________
Telephone:	_____________________
Email:	_____________________

Membership

A one (1) year membership in the Haley Tower Historical & Technical Society
is $35.00.

Members will receive a membership card and a subscription
to the Society's newsletter, to be published quarterly with updates and bulletins as
warranted. Future benefits will be announced as resources allow.

Enclosed is my $35 membership fee for one year.

Enclosed is an additional contribution of $___________.

Mailing Address

Please mail this completed form, along with your remittance, to:

The Haley Tower Historical & Technical Society
PO Box 10291
Terre Haute, IN 47801

Please use the above address for membership forms and contributions only!
If you have questions or comments for us, please see the Contact Information page.
You should receive your receipt and materials within 10 working days.