Membership Application

NUTLEY HISTORICAL SOCIETY
65 Church Street
Nutley NJ 07110
973-667-1528
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The Nutley Historical Society is a not-for-profit organization dedicated to serve the educational, cultural and historical needs of our community.
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I (we) __________________________________ (print name)
wish to _ apply/ _ reapply for membership in
The Nutley Historical Society for the year ____ in the following category:

Annual Student $5.00 ____
Annual Individual $15.00 ____
Annual Couple $20.00 ____
Annual Family $25.00 ____
Lifetime Individual $150.00 ____
Lifetime Couple $200.00 ____
Lifetime Family $250.00 ____
Annual Business Patron $50.00 ____
Lifetime Business $500.00 _____

Additional Donation _______ _____

Signed _____________________________________________

Print Name _________________________________________

email (optional) __________________________________

Address ____________________________________________

City _____________________ STATE _____ ZIP __________

Phone ______________________________________

Send check and application to:

Nutley Historical Society, 65 Church St., Nutley, NJ 07110

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