| I would like to give a Manchester Historical Society membership to: | ||||||||||
| Name: (Mr.) (Mrs.) (Ms) | _______________________________________________________________________ | |||||||||
| Address: | _______________________________________________________________________ | |||||||||
| City/State/Zip: | _______________________________________________________________________ | |||||||||
| Gift recipient's phone and email address: | ( ) _______________ ______________________________________________ | |||||||||
| This gift is from: | ||||||||||
| Name: (Mr.) (Mrs.) (Ms) | _______________________________________________________________________ | |||||||||
| Address: | _______________________________________________________________________ | |||||||||
| City/State/Zip: | _______________________________________________________________________ | |||||||||
| My home phone and email address: | ( ) _______________ ______________________________________________ | |||||||||
| Category: | 
|
Individual | $15 |
|
Family | $25 |
|
Contributing Individual | $40 | |||||
|
|
Student (age 18 or under) | $5 |
|
Corporate | $200 |
|
Contributing Family | $75 | ||||||
|
|
Life - Individual | $250 |
|
Life - Couple | $400 |