Name:____________________________________Maiden Name:____________________

Street Address:_____________________________________________________________

City:_____________________________________________ State:___________________

Zip Code (Including 4 digit extension):_________________________

e-mail address:_________________________

Phone Number (Optional): __________________________

List surnames (limit 4) which you would like to be listed in our index of surnames being researched by members:

Surnames: _________________________________________________________________

__________________________________________________________________________

If you live out of state and want a membership card, please check here _______.

Membership is from Jan. to Dec. and includes 4 newsletters.

Return completed form and a check for $15.00 (single membership) or $20.00 (family membership) payable to the Atchison County Genealogical Society (ACKGS), P.O. Box 303, Atchison, KS 66002-0303.

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