Name _______________________________________________________________

Address_____________________________________________________________

City, State, Zip ___________________________________________________

Ancestral Village __________________________________________________

German Russian Surname (s) _________________________________________

Areas of Interest:  Publicity ___ Newsletter ___ Program ___ Folklore ___

Membership ___  Genealogy ___ Hospitality ___  Historian ___ Officer ___

Renewal ____  New Member ____  Dues for: _____ year (s)

Date _______ Tel #: ______________  Email Number:_____________

Send to Membership Chairman:
Ruthie Galitz, 
314 So 13th Place, 
Norfolk, NE 68701-4809
 
Local Dues are $10.00 U.S. per year.
National Dues are $50.00 U.S. per year.