Greater Buckeye Lake Historical Society
P.O. BOX 1
Buckeye Lake, Ohio 43008

740-928-2920
www.buckeyelakehistory.org

APPLICATION FOR MEMBERSHIP

Date _______________________ Name_________________________________________________________ Address_______________________________________________________ City_______________________________State__________ Zip_________ Phone_______________________Cell/Work Phone____________________ Email__________________________________________________________ Work/Business___________________________________________________ Membership Category:  Individual $20      Couple or Family $35      Organization or Business $75  Sustaining $100      Lifetime: (One Time Payment) $500

Additional Comments & What Talents Would You Like to Contribute:

Please print and fill out this form and send with a check to the address above.