CZECH HERITAGE SOCIETY OF
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?
____________________________________________________________________________________________
Spouse’s Name (including maiden name of wife):
______________________________________________________
Applicant’s Parent’s Names (including Mother’s maiden name):
____________________________________________
Areas of Interest:
Geneology ________ Music
________ Customs ________ History _________
Costumes
________ Language ________ Other _____________________________
Family Names,
Family
Name
____________________________________________________________________________________________
____________________________________________________________________________________________
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
Dues for Members-At-Large
Only are payable to the State Treasurer:
Rita Vanek,
For
Applicant’s Signature:
____________________________________________________
VCCHS Application Form: Rev. 1/1/13