Peoria County Genealogical Society
Post Office Box1489
Peoria, Illinois 61655-1489
Membership Application
July 1st until June 30th
Please fill out this form and send to the above address (Print or Type)

Surname___________________________First________________ Middle_____________

Surname___________________________ First________________ Middle ____________

Street Address_____________________________________ Apartment_______________

City____________________ State_________ Zip Code (+ four digits) ________________

Home Telephone _____________________ Work Telephone ________________________

Birthday________________ Employer __________________________________________

Surnames researching________________________________________________________

Type of Computer Genealogical Program you are using ___________________________

Internet Address ____________________________________________________________

Class of Membership Desired: ...................                  Today's Date:_______________

Note: Senior Memberships are for those who have reached 65+ years. ....................

Donation To:

 

[ ] Regular (for 1 or 2 individuals or institutions) $ 19.00 [ ]Library/Microfilm Fund $ _________
[ ] Senior (for 1 or 2 individuals) . . . . . . . . . . . . . $ 17.00  
[ ] Contributing Membership $ 25.00 [ ] Equipment Fund $ _________
[ ] Life Membership $ 200.00  

Check #_________ 

Total Enclosed $ _________

Make all checks / money orders payable to: Peoria County Genealogical Society & mail to the above address.
 
(Revised - 1 Apr 2002 - JAS)