Membership Form
Join the Ephraim Historical Foundation today!
Today's Date
*
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Month
-
Day
Year
Date
Membership
*
New
Renewal
First Name:
*
Last Name:
*
Spouse's First Name:
Spouse's Last Name:
Check Box if Contact Information Has Changed
Contact Information Has Changed
Primary Street Address:
*
Line 2 / P.O. Box #:
City:
*
State:
*
Zip:
*
Telephone #
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Area Code
Phone Number
Cell Phone #1:
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Area Code
Phone Number
Cell Phone #1 Owner:
Cell Phone #2:
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Area Code
Phone Number
Cell Phone #2 Owner:
Do you receive mail here?
Yes
No
At this Address From:
*
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Month
-
Day
Year
Date
To:
*
-
Month
-
Day
Year
Date
Is this your only address?
*
Yes
No
Street Address #2:
Line 2 / P.O. Box #:
City:
State:
Zip:
At this Address From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Telephone (if different than Primary Address):
-
Area Code
Phone Number
Is there a third address we should be concerned about?
Yes
No
Street Address #3:
Line 2 / P.O. Box #:
City:
State:
Zip:
At this Address From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Telephone (if different than Primary Address):
-
Area Code
Phone Number
Additional comments related to residency:
Email Address #1:
myname@example.com
Email Address #1 Owner:
Email Address #2:
myname@example.com
Email Address #2 Owner:
Please indicate which email address(es) you want listed in the Membership Booklet:
Email address #1
Email address #2
Both
Neither
How would you like to receive your newsletters?
*
E-mail (saves postage and printing)
Print (by mail)
Both
Please select a membership
*
Founders' Circle $1000 & up
Sustaining $500 - $999
Contributing $250 - $499
Supporting $100 - $249
Regular $75 - $99
Please enter membership amount (e.g. 100.00)
*
Would you like to donate to the Heritage Fund
*
Yes
No
Please enter Heritage Fund donation amount (e.g. 100.00)
Total
Total
*
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USD
Total
Please note that annual dues barely cover printing, mailing, and some administrative costs. Our annual operating expenses exceed the amount presently generated by the developing Heritage Fund. Your help is needed and greatly appreciated!
Submit (You'll be directed to Paypal securely)
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