Membership Application

Ladysmith & District Historical Society

Name: ____________________________________________________________________

Address: ___________________________________________________________________

City:_______________________________ Postal Code:_____________________

Phone: ____________________________ Fax: ____________________________________

Email Address: _________________________________________________

Areas of Interest (check any you would like)

____________________________________________________________________________

(__) Individual Member $15 (___) Family $20 (__) Corporate $30

Signature: _______________________________________ Date: _________________________

(____) Check if you wish to be listed in our member's only directory on the website.
Print this form and bring it to the office, or mail it along with a check to the address below (ctrl + p on keyboard)

#4 622 First Avenue, PO Box 813, Ladysmith BC V9G 1N2
Telephone (250) 245-0100

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