CZECH HERITAGE SOCIETY OF TEXAS

Membership Application

 

Date: _________________

 

Application for membership for ___Victoria County_____ Chapter or State At-large Member ONLY ______________

††††† ††††††††††††New: ________††††††††††††††††††† Returning: ________†††††††††††††††††† Multi-Chapter: ________

If multi-chapter, what is your home Chapter? _________________________________________________________

Name: _______________________________________________________________________________________

†††††††††††† ††††††††††††First†††††††††† †††††††††††††††††Middle†††††††††††††† †††††††††(Maiden Name)††††† †††††††††††††††††††Last

 

Address: _____________________________________________________________________________________

†††††††††††††††††††††††† Number and Street†††††††††††††††††††††††††††††††††††††††††† City†††††††††††††††††††††††††††††††† State††††††††††††††††††††††††††† Zip + 4

 

Phone:Home (____)______________Work (____)_____________ E-mail: _______________________________

Birth Date: ___________________________Birth Place: ______________________________________________

What do you do and what skills or expertise would you be willing to volunteer to our organization?

____________________________________________________________________________________________

Spouseís Name (including maiden name of wife): ______________________________________________________

Applicantís Parentís Names (including Motherís maiden name): ____________________________________________

Areas of Interest:†††††† Geneology ________††††††††† Music ________††††††††† Customs ________†††††††† History _________

†††††††††††††††††††††††††††††††††† Costumes ________†††††††††† Language ________††† Other _____________________________

Family Names, Ancestral Villages, and Locations in USA that you are researching or would like to research:

††††††††††† Family Name†††††††††††††††††††††††††† Ancestral Village†††††††††††††††††††††††††††† Immigration to what US area?

____________________________________________________________________________________________

____________________________________________________________________________________________

 

Membership Dues/Levels

State Dues . . . . (general and membership at large) . . . .†††† $10.00†† Plus Chapter Dues __$5.00 __ Total: _$15.00_

State Contributing Dues . . . . . . . . . . . . . . . . .. . . . . . . . . . ††† $25.00†† Plus Chapter Dues _________ Total: ________

State Supporting Dues . . . . . . . . . . . . . . . . . . . . . . . . . . . .††† $50.00†† Plus Chapter Dues _________ Total: ________

State Patron Dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00†† Plus Chapter Dues _________ Total: ________

State Youth Dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$2.00†† Plus Chapter Dues _No Chrg._ Total: __$2.00__

Membership Dues are Payable To:††† Victoria County Czech Heritage Society

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† P.O. Box 1145

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Victoria, TX77902

 

Dues for Members-At-Large Only are payable to the State Treasurer:Rita Vanek, P.O. Box 901, El Campo, TX77437-0895

For CHS State and Chapter Information, visit our website: www.czechheritage.org

 

Applicantís Signature: ____________________________________________________

 

VCCHS Application Form: Rev. 1/1/13