Membership Form
Join the Ephraim Historical Foundation Today!
Today's Date
*
-
Month
-
Day
Year
Date
Membership
*
New
Renewal
First Name:
*
Last Name:
*
Spouse's First Name:
Spouse's Last Name:
Door County Street Address:
*
PO Box #:
City:
*
Zip:
*
Telephone #
-
Area Code
Phone Number
Cell Phone #1:
-
Area Code
Phone Number
Cell Phone #1 Owner:
Cell Phone #2:
-
Area Code
Phone Number
Cell Phone #2 Owner:
Do you receive mail here?
Yes
No
At this Address From:
*
-
Month
-
Day
Year
Date
To:
*
-
Month
-
Day
Year
Date
Is this your only address?
*
Yes
No
Additional comments related to residency:
Address #2:
City:
State:
Zip:
At this Address From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Telephone (if different than Door County Address):
Is there a third address we should be concerned about?
Yes
No
Address #3:
City:
State:
Zip:
At this Address From:
-
Month
-
Day
Year
Date
To:
-
Month
-
Day
Year
Date
Telephone (if different than Door County Address):
Email Address #1:
Email Address #1 Owner:
Email Address #2:
Email Address #2 Owner:
Do you want your email address listed in the Membership Booklet?
Yes
No
If yes, please indicate which email address(es) you want listed in the Membership Booklet:
Email address #1
Email address #2
Both
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
*
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)
Should be Empty: