Application Form - (Print out a copy)

Dr./Mr./Mrs./Ms./Miss:

Spouse First Name:

Address

City/State & Zip

Telephone (day)

E-mail

Ages & # of children currently living at home

I would like to support Old City Park for:  1 year		2 years (circle one)

I wish to join at the following level of membership:

Scout $60 _____ Family Scout $75 _____ Settler $125 _____

Pioneer $300 _____ Trailblazer $600 _____

Junior Curator�s Circle $550 _____ Curator�s Circle $1,250 _____

I wish to decline membership benefits & make my gift 100% tax deductible _____

I would like to pay using Cash ____ Check____ Credit Card______

Visa_____ MasterCard_____ AMEX _____ Exp. date___/____

Card Number __/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__

Signature: _____________________________________

Please make checks payable to Dallas County Heritage Society