MEMBERSHIP FORM

DATE:  _________________

Membership Year is from date we receive, and is good for 1 year

Type of membership: (Please Check One)   New Member ____    Membership Renewal _____
OGS Member   Yes _____  No  _____

•	Single:     $20.00                                                    
•	Family:     $25.00
•	Student:     $5.00

Name:  ______________________________________________________________________

Spouse's Name:  ______________________________________________________________

Names of Children:  ____________________________________________________________

_____________________________________________________________________________

Street Address:  _______________________________________________________________

                  _______________________________________________________________

City:  __________________________________________  State:  _______________________

Zip:  ______________  E-Mail Address:  ____________________________________________

Telephone:  Area Code  (_____)  __________________________

Surnames:          _______________________________________________________________

                     _______________________________________________________________

Mail to:		Hardin County Genealogy Society
		P. O. Box 520
		Kenton, OH 43326-0584