Knox County Historical Sites, Inc.


Membership Application and Contribution Form
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Please print or type the following information:

NAME: ________________________________________________________________

ADDRESS: _____________________________________________________________
         
         _____________________________________________________________


Check one of the following if you wish to become a member of the
Knox County Historical Sites, Inc. :     


		___  Annual Dues - $10.00 / year

                ___  Lifetime Membership - $100.00
                
                 
If you wish to make a contribution to the Knox County Historical
Sites, Inc.  check the following.  Note: This does not cause you to
join the Sites unless one of the above items was checked.


		___  My tax-deductable contribution of $_________
                     is enclosed.


Please make your check payable to:  Knox County Historical Sites, Inc.


Mail this completed form to:

	Knox County Historical Sites, Inc.
	c/o Knoxville City Hall
	Public Square
	Knoxville, IL. 61448