Please print this form and mail it with your check Payable to Pittsford Historical Society, Inc. Send To:

Doris Hoare
PO Box 187
Pittsford, VT 05763.

Name__________________________________________________________

Street/Apt #__________________________________________________________

Town __________________________________  State _______  Zip_____________

Please check amount enclosed:

Single:  $15 __;  Family:  $20 __;   Contributing:  $25 __;   Sponsor:  $50 __;

Life member:  $200 per person __