AFRICAN/AFRICAN AMERICAN HISTORICAL SOCIETY
436 East Douglas Ave.
Fort Wayne, Indiana 46802
260-420-0765 Fax: 260-426-9773
Email:fwaahm@aol.com
Membership Application
Name's)/Organization:
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Street:
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Date________________________
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State:
Zip code
Telephone: Fax:
This society is a 501(c)3 tax-exempt, not-for-profit organization.
Individual Memberships
____Under 16 Member $5 ____ Contributing Member $100
____Adult Member $25 ____ Sustaining Member $500 & above
____Family Member $40 ____ Patron Member $5000 & above
____Sr. Citizen Mem. $10
Organization & Business Memberships
____Organization Member $100 ____ Gold Member $5000
____Bronze Member $500 ____ Platinum Member $10,000
____Silver Member $1000
Thank you for your membership without your support it would be impossible to keep the doors of this organization opened.
Your support is needed and appreciated.
Return form with your payment to:
African-African American Historical Society, 436 East Douglas Ave., Fort Wayne, IN 46802
(Revised January 2005)