MAIL-IN  MEMBERSHIP/DONATION/ORDER FORM

				
Please print out this page and send completed form with check or
money order to:

   U.S.L.S.S. Living History Association
   P.O. Box 32
   Rodanthe, NC 27968


Make Checks Payable To:   U.S.L.S.S. L.H.A.


Name(s):           _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 

Address:           _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 

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City, State, Zip   _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 


Telephone          _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Email              _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


Membership Level/Donation:  (select below)

   [__] Individual  $  10 /year
   [__] Family      $  25 /year
   [__] Business    $ 100 /year
   [__] Donation    $_ _ _ _ _


Comments:          _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 

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                     THANK YOU FOR YOUR SUPPORT!