5thPA Membership application

FIFTH PENNSYLVANIA REGIMENT         REVOLUTIONARY WAR HISTORIANS

Purpose of this Document:  To register members of the Fifth Pennsylvania Regiment to have full benefits including insurance coverage necessary to participate at events with this unit.  This required premium reimburses the Regiment for the monies already issued towards the groups Insurance Premium.

Annual Dues:  The annual dues are payable immediately or prior to the first event attended.  Membership and Insurance Coverage is good for the remainder of the calendar year.

Single            $35.00                        Husband & Wife/Family            $55.00

  Under 25 yrs. of age                 $20.00

–  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –  –

            Membership Application/Annual Dues                        Year:       2016

Amount: ________ 

All members must fill out this form in its entirety to have full Insurance Coverage

Name(s): ____________________________________

                 ___________________________________           

                 ___________________________________           

                 ___________________________________           

                 ___________________________________        

Address:            ______________________________________________________________

            ______________________________________            ZIP ___________________

Telephone: _____________________________________  E-Mail ________________ 

Note:  Name, Address, Telephone # and E-Mail address will be printed on a

            Membership Listing unless otherwise notified.

 Please make checks payable to:  Fifth Pennsylvania Regiment

Mail to:           John Godzieba

                        Treasurer, Fifth PA Regiment