(Please print this form)

Name: ___________________________________________________________

Address: _________________________________________________________

City: ___________________________  State: ___  Zipcode: _____

Email: ____________________@___________________________

Telephone: (____)  ____-______

Membership type: (Please check one)

_____ Annual - $10.00

_____ Life - $100.00

______ Send the quarterly newsletter to my email address.

______ Send the quarterly newsletter to my home address.

Send your completed application and payment (cash or check made payable to MAHS) to:

Monticello Area Historical Society
P. O. Box 463
204 N. Main St.
Monticello, WI 53570