2015 MEMBERSHIP FORM
NORTH HAVEN HISTORICAL SOCIETY
Cultural Center
27 Broadway, North Haven, CT 06473
 New Membership
 Renewal
(please print)
NAME(s)
__________________________________________________________________________________________
STREET
__________________________________________________________________________________________
TOWN
_________________________________________________________ STATE ________ ZIP______________
PHONE
___________ - __________ - __________________________
EMAIL
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ @ __ __ __ __ __ __ __ __ __ . __ __ __
Annual Membership:
Life Membership:
___ Individual
$15.00
___ Individual
$ 125.00
___ Family
$25.00
___ Family
$ 200.00
___ Supporting $75.00
___ Benefactor $1,000.00
Please make all checks payable to the North Haven Historical Society and send to the above address.
Please mark the envelope with the word "MEMBERSHIP"
Volunteer Service (please check all that interest you!):
___ Fundraising
___ Preservation
___ Publicity
___ Exhibits
___ Hospitality
___ Programming
___ Membership
___ School Tours
___ Archival Organization/Research
___ Events/Presentations
Donation(s):
___ To support the work of the Society
$ ___________________
___ To sustain the Furnival Scholarship* Fund $ ___________________
Total: $____________________
*Awarded to a graduating senior at North Haven High School pursuing an academic program related to
history or museum studies.