Membership Form

Membership Level: Check One

Ϝ  Family.......$20.00

Ϝ  Individual.......$15.00

Ϝ  Senior.......$10.00

Ϝ  Business.......$50.00

Ϝ  Corporate.......$100.00

Ϝ  Benefactor......$500.00

Ϝ  New Membership      Ϝ  Renewal      Ϝ  Gift Membership

Name: ______________________________________________________________

Address: ____________________________________________________________

City:_____________________________ State: _________Zip Code: ____________

Phone: ___________________________ E-mail: ____________________________

Gift membership from: _________________________________________________


Please fill it out as completely as possible. After completing the form, mail it to:
Historic New Carlisle, Inc.
P.O. Box 107
New Carlisle, IN 46552
Thank you for your support!