Pike County,

NOTICE   =   Your phone no. and E-Mail address will not be sold or given to anyone, without your permission

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Name   ________________________________________________________________

Address    ______________________________________________________________

City   ________________________  State    ______________   Zip   _____ / ____

Phone  ___ / ___ / ____                 E-Mail   ___________________ @ ____________________

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Office use only  = Dues Paid.= No ---   Yes ---   Check No. __________  Date Paid. __________    Membership No. _____

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List surnames  you are researching

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      Print this form to your printer. Fill out and then mail to   = 

     Pike County Genealogy Society = 1008 East Maple St. =  Petersburg, Indiana 47567

     Please enclose check for membership = $ 15.00 per year per person.

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