Membership Application

 

____New Member  ___Renewing Member

Name_______________________________

Address_____________________________

City, St., Zip__________________________

 

Phone______________________________

E-mail_______________________________

 

 

___Preserver

___Steward

___Conservator

Gift Recipient’s Name_________________

Address_____________________________

City, St, Zip__________________________

___Restorer

Gift Recipient’s Name_________________________

Address____________________________________

City, St, Zip__________________________________

 

 

A check payable to Old Saybrook Historical Society is enclosed in the amount of $___________.  Please mail to:  P.O. Box 4, Old Saybrook, CT 06475