Czech Heritage Society of Texas Membership Application

THE CZECH HERITAGE SOCIETY OF TEXAS

DEDICATED TO THE PRESERVATION OF OUR CZECH HERITAGE

Date: _______________

Application for membership for ___________________ Chapter or _At Large

New Returning
Multi-Chapter (list home chapter __________)

Name_____________________________________________________________________
First Middle (Maiden Name) Last

Address__________________________________________________________________
Number and Street City State ZIP+4

Phone Numbers: Home (_)____ Business (_)_________

E-Mail _@

Birth Date ____________________

Birth Place ___________________________________________________________

What do you do, and what skills or expertise would you be willing to volunteer to our organization?
_______________________________________________________________________

Spouse's Name (including wife's maiden name)
_______________________________________________________________________

Applicant's Parents' Names (including mother's maiden name)
_______________________________________________________________________

Areas of Interest (check all that apply)
___ Genealogy
_ Music
_ Customs
_ History
_ Costumes
_ Language
_ Other (please elaborate) ______________________________________________

Family Name Ancestral Village Immigrated to what area in US?

__

MEMBERSHIP LEVELS AND DUES

_____ State Dues (general and members at large)	$ 10.00	$_______
_____ State Contributing Dues	$ 25.00	_______
_____ State Supporting Dues	$ 50.00	_______
_____ State Patron Dues	$100.00	_______
_____ State Youth Dues	$ 2.00	_______
_____ Chapter Dues	See County Website	_______

	Total enclosed	$ _______

_________________________________________
Member signature

Dues for Members at Large ONLY are payable to state treasurer:
    Rita Vanek
    P. O. Box 895
    El Campo, TX 77437

Membership period is January 1 - December 31. If you are joining a local chapter, state and chapter dues are payable to the local chapter treasurer.

To find the chapter information and membership contact for your county go to the Czech Heritage Society of Texas County Chapter Information page.

(Print this page and mail to the chapter you are joining)