Membership Application
(Print and complete this form and submit it with your membership dues)

Collinsville Historical Association
P.O. Box 849
Collinsville, AL 35961

Type of Membership:

 Individual ( $25 ) Family ( $35 ) Student ( $15)
In Memory Of ($________ )                              Donation ($________ )

Please  Print

Name: ______________________________________________________________________
Address: ______________________________________________________________________
City/State/Zip: ______________________________________________________________________
Telephone: ______________________________________________________________________
Email: ______________________________________________________________________
 

 

Validation for Student Membership
School:
______________________________________________
Year of Graduation: __________

Signature of Teacher:
______________________________________________

 

Your membership and the newsletter begin when the membership application and dues are received.  Member names are listed in the following newsletter.

 

Welcome and thank you for you support!!!