Annual Membership Contribution

                        Amite County Historical and Genealogical Society

                                                        PO Box 2

                                                Liberty, MS 39645

Check or circle choice of membership type
( ) $15.00–Individual	( ) $50.00 – Sponsor or Memorial
( ) $25.00–Family	( ) $200.00 – Lifetime
( ) $10.00–Student (under 18)	( ) $10.00 – Senior (over 65)

All contributions are tax deductible.  Please make checks or money orders payable to

Amite County Historical and Genealogical Society

PLEASE PRINT:

Name: ____________________________________________________________________

Address: __________________________________________________________________

City: ______________________________ State: ______ Zip: __________ Zip+4: ________

Telephone(s): ______________________________________________________________

E-mail address(es): _________________________________________________________

Thank you for joining the Amite County Historical and Genealogical Society. Your

contribution helps us continue to collect and preserve historic treasures from

Amite County’s past, as well as to promote family history. Membership also

provides an opportunity to attend programs and participate in special events.

I am interested in helping with:

( ) Archives ( ) Membership ( ) Programs  ( ) Newsletter

( ) Other (specify): __________________________________________________________