EHF Membership Form

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:
Check Box if Contact Information Has Changed

Contact Information Has Changed
Primary Street Address: *
Line 2 / P.O. Box #:
City: *
State: *
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
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!
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