MARCUS HISTORICAL SOCIETY

PO Box 321 Marcus IA 51035-0321

Membership Application

            Please Print

Full Name: ___________________________________________ Phone Number: (_____)_____________

Address: _____________________________________________________________________________

City: _______________________________________________ State: ___________  Zip: ___________

Mailing Address (if different from above):

_____________________________________________________________________________________

City: _______________________________________________ State: ___________  Zip: ___________

Email Address: ________________________________________________________________________

Type of Membership (check one):

(  ) Individual - $10/yr               (  ) Family - $15/yr                   (   ) Sustaining - $25/yr

            (  ) Pioneer - $50/yr                  (  ) Century - $100/yr              

(  ) Founder -- $500 lifetime membership -- only available until October 1, 2007!

If Family Membership or higher level, please list the names of other family members

(spouse, children under age 18, must live in same household):

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Do you subscribe to the Marcus News?  (circle one)    Yes    or     No