Membership Renewal / Application Form

Name:                                                                                  

Date:                                     

Maiden Name (if Female):___________________

Family Member's Name:                                              

Street Address:                                                           _

City / State / ZIP:                                                         __

Phone: Home  (      )                       _____________ _

Business  (     )                       __________________ 

E-mail Address:                                                              

Please check one of the following:

Renewal: [    ]    New Member:  [    ]

Single ($30) [    ]   Family ($40) [    ]

Jr./Student under 18 ($5)  [   ]
Founding Member ($100) [    ]

Life, under 10 yrs. ($300) [   ]
Life,10 yrs + ($150) [   ]    Patron/Business $100 [   ]

(For office use only)

( Date received                  Amount $           For Year(s)             )

*Please Print this Form *

Please complete application with payment by check or money order (no cash) and return to:

Fred Hart Williams Genealogical Society

Detroit Public Library-Burton Historical Collection
5201 Woodward Avenue
Detroit, MI 48202