Membership Form

The Millet and District Historical Society
C/O Millet and District Museum and Exhibit Room
P.O. Box 178 5120-50 Street
Millet, Alberta Canada

T0C 1Z0

PLEASE PRINT

Name: ______________________________________________



Address: ___________________________________________
 

____________________________________________________



Daytime Phone: (_____)______________________________



E-mail: ____________________________________________ 



Payment Enclosed by cheque or money order $_____.___

Please send me a tax-deductible receipt for my donation of $ __________ over and above the membership fee.

Please make cheques payable to the Millet and District Historical Society.

Please print this form and mail it to the above address.