Locust Valley Historical Society

Annual Dues $10.00

For the Year January 1, ________ - December 31, _____________

My check for $ ________________ is enclosed for Annual Membership.

Mr./Mrs./Ms./Miss __________________________________________

Adress__________________________________________________

City _________________________ State ________ Zip ___________

Telephone No. (optional) ________________

My Membership is:

New _______

Renewed ___

Please make check payable to Locust Valley Historical Society.
Membership contributions are tax-deductible to the extent allowed by law.