MEMBERSHIP APPLICATION

               American Historical Society of Germans from Russia


Name of Husband ______________________________________ Birthdate _____________

Name of Wife _________________________________________ Birthdate _____________

Address ______________________________________________________________________

City, State, Zip _____________________________________________________________

Telephone ____________________________________________________________________

Email Address ________________________________________________________________

Anniversary Date _____________________________________________________________

Village ______________________________________________________________________

Surname ______________________________________________________________________


International Dues         $50.00                New Member ____  Renewal ____
                 after Jan. 31, late renewal chg $2.00
Local Chapter Dues         $6.00 single          New Member ____  Renewal ____
                           $8.00 couple/family
                 No late renewal charge

Please make checks payable to Denver Metro Chapter AHSGR and mail to:

Barbara Bretz, Membership Chairman, 6733 Reed St, Arvada, CO 80033-4055