Name_____________________________________________Spouse___________________________________

Mailing Address______________________________________________________________________________

City _______________________________________________________________________________________

State________________________________Zip Code ____________-________

Telephone (____) _____-________

E-mail Address____________________________________________________________

Membership:       New______ Renewal_______

Membership yearly dues — $10.00 per person

Please return with membership fee to:

  Taylor County Historical Society
  118 East Main Street
  Perry, Florida  32347