Trademarked logo of the Czech Heritage Society of Texas - the silver lion of Bohemia superimposed on an outline of Texas in red

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)