Name: _______________________________________________________

Spouse's Name: _________________________________________________
(If Family Membership)

Address:
Street:_________________________________________________________

City:  _________________________________________________________

State:_________________    Zip:  ___________________

Phone:
Home:  _________________   Work: ___________________

Email: ____________________________________________

______    Single Membership ($ 20.00 Annual Dues)
______    Single Life Membership (One Lifetime Payment of $ 250.00)
______    Family Membership ($ 30.00 Annual Dues)
______    Family Life Membership (One Lifetime Payment of $ 300.00)
______    Contributing Member - Person, Organization, School, Libraries (Annual Dues ( $ 50.00)
______    Sustaining Member (Annual Dues $ 50.00)
______    Business and Professional Membership (Annual Contributions $ 400.00)
______    Patron Membership (Contributions of $ 500.00)
______    Legacy Member (Contributions of $ 1,000.00 +)
______    I would like to make an Endowment to the society please have someone contact me.

Please make check payable to South County Historical Society
Mail to:
South County Historical Society
4378 Southview Way
St. Louis, Missouri 63129
314-487-3607