The Railway & Locomotive Historical Society, Inc

2009 Membership Application/Renewal Form - USA

MEMBERSHIP YEAR RUNS FROM JANUARY 1 THROUGH DECEMBER 31

RAILWAY & LOCOMOTIVE HISTORICAL SOCIETY DUES (All members must pay these dues)

Please choose your level of membership and mark your selection on the list below.

___Regular ___Sustaining

$32.00 $100.00

___Family ___Patron

$37.00 $250.00

___Contributing

$60.00     ___Library/Institutional     $65.00

Optional donation to R&LHS $_______

Enter the sum of your membership and optional donation here (Line 1) $_______

CHAPTERS: Chicago Golden Spike Ogden Lackawanna Mid-South New York Pacific Coast Southeast Jacksonville Southwest El Paso Southern California -- E-mail delivery Southern California -- Postal delivery

DUES     $15.00 $12.00 $25.00 $10.00 $27.50 $20.00 $15.00 $12.00 $15.00 $20.00

OPTIONAL DONATION ________ ________ ________ ________ ________ ________ ________ ________ ________

TOTAL __________ __________ __________ __________ __________ __________ __________ __________ __________

Add total amount in each chapter line you selected and enter the sum here                      (Line 2) $_______

Add the amounts on lines 1 and 2 above and enter the total in the box

$

Payment may be made by check (Payable to R&LHS) or credit card (Complete charge form below)

Mail this entire form (or a photocopy) and your check or credit card information to:

R&LHS Membership, PO Box 62698, Colorado Springs, CO 80962-2698

I do not want my address made available to any other agency.

HOW DID YOU LEARN ABOUT R&LHS? ____________________________________________________________

Your Name ______________________________Spouse’s Name_____________________

Mailing Address_____________________________________________________________

City_____________________________________ State_____ Zip + 4_________________

Home Phone ____________________email ______________________________________

OFFICE USE ONLY: P ___ CS ___ DEP ____ Pmt By: CH ____ CC____ DATE REC’D______________

*CREDIT CARD YOU WISH TO USE VISA _____ OR        MASTER CARD ________

*NAME AS IT APPEARS ON CARD (PLEASE PRINT) _______________________________

*CARD NUMBER _________ _________ _________ _________ *EXP. DATE ____________

*SIGNATURE__________________________________________________________________

*ALL LINES MUST COMPLETED FOR YOUR CREDIT CARD CHARGE TO BE ACCEPTED

For office use only
NAT'L________	CH________	GS________	LAC________	NY________
PCC________	SoC________	SoE________	SoW________	MS________	TOTAL_________