MEMBERSHIP APPLICATION AND RENEWAL

(Please make checks payable to the the Wayland Historical Society.)

Name: .............................................................................................

Address: ..........................................................................................

Phone: .............................................................................................

This is a NEW membership....................RENEWAL .......................

TYPE OF MEMBERSHIP

.......... Junior $2.00                              ............. Contributing $50.00

.......... Single Adult $15.00                   ............. Patron $100.00

.......... Family $25.00                           ............. Life $350.00

Additional contributions to the Grout-Heard House maintenance fund $...........

Please mail to: Wayland Historical Society, Inc.

P.O. Box 56

Wayland, MA 01778