MHA Membership Application

MELUNGEON HERITAGE ASSOCIATION MEMBERSHIP FORM

 COST OF MEMBERSHIP IS $12.00 PER YEAR

PLEASE COMPLETE ONE MEMBERSHIP FORM FOR EACH PERSON.  THREE APPLICATIONS ARE PROVIDED BELOW.  PLEASE SEND COMPLETED FORMS TO P.O. BOX 3604, MARTINSVILLE, VA 241112, with a check for $12.00 payable to MHA, or apply and pay dues through PayPal using the “buy now” button.

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(Please print)

LAST NAME: ………………………FIRST NAME: …………………………………….. M.I.: ………

ADDRESS:…………………………………………………………………………………………

CITY:………………………………………………………STATE: ………….. ZIP: ……………………..

TELEPHONE: ……………………………………  CELLPHONE: …………………………………………………..

EMAIL: …………………………………………………….. WEBPAGE: ……………………………………………………….

Check one or both (optional) ____ Identify as a Melungeon Descendant ____ Supporter of MHA

(Please print)

LAST NAME: ………………………………… FIRST NAME: ………………………… M.I.: ………

ADDRESS:……………………………………………………………………………………………………………

CITY:…………………………………………………………STATE: ………….. ZIP: ……………………..

TELEPHONE: ……………………………………… CELLPHONE: …………………………………………………..

EMAIL: ……………………………………………… WEBPAGE: ……………………………………………………….

Check one or both (optional) ____ Identify as a Melungeon Descendant ____ Supporter of MHA

____________________________________________________________________________________(Please print)

LAST NAME: ………………………………… FIRST NAME: ………………………… M.I.: ………

ADDRESS:……………………………………………………………………………………………………………

CITY:…………………………………………………………STATE: ………….. ZIP: ……………………..

TELEPHONE: ……………………………………… CELLPHONE: …………………………………………………..

EMAIL: ……………………………………………… WEBPAGE: ……………………………………………………….

Check one or both (optional) ____ Identify as a Melungeon Descendant ____ Supporter of MHA