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?

____________________________________________________________________________________________

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, 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, TX  77902

 

Dues for Members-At-Large Only are payable to the State Treasurer:  Rita Vanek, P.O. Box 901, El Campo, TX  77437-0895

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

 

Applicant’s Signature: ____________________________________________________

 

VCCHS Application Form: Rev. 1/1/13