Iowa County Historical Society
Membership Form

Membership Type:		
__ Individual (annual) - $10.00	
__ Individual (5-year membership) - $40.00
__ Couples (annual) - $15.00
__ Couples (5-year membership) - $60.00
__ Historian (annual) - $25.00
__ Master Historian (annual) - $50.00

Membership Status:
__ New Membership
__ Renewal

(membership year is July 1st through June 30th and membership fees are subject to change without notice)


Name: _________________________

Spouse or additional name: _________________________ 

Address: _________________________

City: _________________________

State/Province: _________________________

Zip/Postal Code: _________________________

Email: _________________________

Home Phone: _________________________

Business Phone: _________________________


Payment Type:
__ Check enclosed (for use if mailing Ð please make payable to the Iowa County Historical Society)

If in addition to becoming a member, you would like to make a contribution to the Iowa County Historical Society, please indicate the amount below:

Contribution:  	 _________________________


Please send the completed form, membership fee(s) and/or contributions to:
Marie Sersch / Treasurer
Iowa County Historical Society
106 East Pine Street
Dodgeville, Wisconsin 53533