APPLICATION FOR MEMBERSHIP
LOOMIS BASIN HISTORICAL SOCIETY
Please complete the form below. After submitting the form you may send us a check, payable to Loomis Basin Historical Society. Please print this form for your tax records. If you want a "paid invoice," please indicate on this form. We will mail it to you once we have received your check.

* Indicates required fields.

INDIVIDUAL MEMBERSHIP ($10 each) *Name:>>>
Company:>
*Address:>>
Address:>>
*City:>>>>> *State: *Zip:
*Telephone Phone:>
Fax:>>>>
*E-mail Address:>

ADDITIONAL FAMILY MEMBERS ($5 each) Family Member 1:>>>
Family Member 2:>>>
Family Member 3:>>>
Family Member 3:>>>

SAFE ORGANIZATIONAL SITE - PRIVACY STATEMENT:

All information sent to the Loomis Basin Historical Society remains confidential, is held in trust and is shared with no other parties. In addition, this form has secure information designs.

Because credit cards are not taken over the internet, a new member application's risk on this form is considered minimal.

Please click the Submit button when your application is complete and don't hesitate to contact us at loomishistorical3@ppgn.com should you have any questions.

We recommend that you print this applicaton, for your records, before submitting.