Please provide the following contact information:

First Name
Last Name
Title
Company
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail
URL

Please choose your membership level based on full time employees:

1 - 5 Employees       $125.00 6 - 25 Employees     $300.00 26 - 100 Employees     $750.00 Over 100 Employees     $1,000.00

Check #
Credit Card	VISA MasterCard
Cardholder Name
Card Number
Expiration Date

Please print out the completed form and send it to:

Beverly Historical Society

Membership Secretary

117 Cabot Street

Beverly  MA  01915-5196