Date of Application ___/___/___

Name:________________________________________
         Last              First        Middle Initial

Address:_____________________________________
		        Street                  City                 State

Telephone: Home____________ Work_____________

Email: _______________________________________

Would you like your telephone number listed in the membership directory?
		YES _______ NO_________
		(if yes, which one?) HOME _______ or WORK _________

Would you be interested in serving as a committee member?
		YES _______ NO _________

		(if yes in what area?)_________________________________


Would you be interested in volunteer work? YES _____ NO ______

		(if yes in what area?)_____________________________________

		_____________________________________________________

1 Year Membership $20.00

Extra Contribution for Building Fund
[ ]$1,000  [ ]$500  [ ]$100  [ ]$50  
[ ]$25  [ ]Other $_______

Each member will receive a quarterly newsletter and any special mailings.
		
Please make check payable to:

		Long Beach Heritage Museum
		P.O. Box 14641
		Long Beach, CA 90803
		______________________________________________________
		Office use only:
		Application accepted ____/____/____
		Membership number ______________
		Renewal notice sent ____/____/____