North East Historical Society Membership Application

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Please type in all information and print form to mail in.
First Name
Last Name
Address
City
State
Zip
Phone
Email
Membership Level	Please choose Membership Level Single $20.00 Student (under 18) $3.00 Family $25.00 Sponsor $100.00 Lifetime $250.00
Please print out and send with payment to this mailing address:	North East Historical Society PO Box 483 North East, PA 16428