Buffalo & Erie County Historical Society Membership Application

Please print this page, print all information, and return with payment in U.S. funds to
Buffalo & Erie County Historical Society
24 Nottingham Court
Buffalo, New York 14216-3119

(Please circle one)   Mr.        Mrs.       Ms.       Miss       Dr.       Mr & Mrs.

Name(s) _______________________________________________________________

Address _______________________________________________________________

City/State/Zip+4 _________________________________________________________

Phone (day) ____________________ (evening) ________________________

E-mail _________________________________________________________

For Family/Grandparents, birth dates (mm/dd/yy) of children 16 and under:

______________ ______________ ______________ _____________

     Membership Level

                    ___ Sustaining ($75)                      ___Grandparent/Senior ($40)
                    ___ Family/Household ($50)           ___ Individual ($35)
                    ___ Teachers (additional $5)           ___ Student ($25)
                   

     Method of Payment

     _____ Check enclosed, payable to BECHS in U.S. funds

     _____ MasterCard      ______Visa Exp. Date

     Card # _______________________________________

     Signature _____________________________________