MCHS Registration Form
First Name:
Last Name:
Street Address 1:
Street Address 2:
City:
State:
Zip + 4:
Phone:
e-mail Address:
Sex:
Male
Female
Age:
_0 - 15
15 - 21
21 - 30
31 - 40
41 - 50
51 - 60
Above 60
MCHS Member:
Yes
No
Receiving Newsletter:
Yes
No
Comments:
(Max. Length = 200 characters)
Entry checking requires entry in all fields but one. Entries are not validated.
Submit Form:
Miller County Historical Society
P.O. Box 57
Tuscumbia, MO 65082
http://www.MillerCountyMuseum.org
© 2016 - Miller County Historical Society
millercountymuseum@att.net
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