WACHOVIA HISTORICAL SOCIETY

MEMBERSHIP FORM

Name: _______________________________________________________

Address: ____________________________________________________

City: _______________________________________________________

State: ________________________________ Zip: ________________

E-mail: _____________________________________________________

INDIVIDUAL/FAMILY MEMBERS
   Student                   $10     _____
   Senior Citizen            $15     _____
     (Individual/Couple)
   Individual                $25     _____
   Family                    $35     _____
     (Two or more)

LEADERSHIP MEMBERS
   Salem Guild	             $50    _____
   Committee of 1895         $100    _____
   Bethabara Associates      $250    _____
   Herrnhut Associates       $500    _____
   Order of Wachovia         $1,000  _____

ORGANIZATIONAL MEMBERS
   Non-Profit Organization   $25     _____
   Commercial/Professional   $25     _____

Signature: __________________________________________________

Date: _______________________________________________________

Annual dues are payable by the date of membership. Contributions are fully tax deductible within limits of federal and state laws. Please make all checks payable to “Wachovia Historical Society” and mail to: Wachovia Historical Society, P.O. Box 20803, Winston-Salem, NC 27120-0803. For more information on the Society, please call (336) 722-5020.