COLLINS REGIONAL HISTORICAL SOCIETY
APPLICATION FOR MEMBERSHIP
Date ___________
I (We) hereby apply for membership in the Collins Regional Historical Society
(please print clearly):
Name _____________________________________________________
(First and Last name as you wish it to appear on your name badge)
Name _____________________________________________________
(First and Last name as you wish it to appear on your name badge)
Address (physical) ___________________________________________________
City _____________________________ State _____ Zip ____________
Telephone _________________ Email ___________________________
Address (mailing) ___________________________________________________
City _____________________________ State _____ Zip ____________
Telephone _________________ Email ___________________________
Please indicate the topics and activities which interest you ():
Lectures Classes (series) Museum Tours Motor Tours Walking Tours
Field Research Library Research Computer Research
Historical Archeology
Oral History Videography Restoration Displays
Writing Acting Working with children
Fund Raising
Genealogy
Other (specify) ________________________________
Membership and Dues:
Annual Dues Level () 2013 – 2014 (Dues may be raised after June 2014 to keep up with inflation) Individual & Family Memberships
Individual membership $10.00 . . . . . . . . . . . . . . . . . . . . . .
Additional adult family member $5.00 . . . . . . . . . . . . . . .
Children 5 & under Free with paying Adult Membership………….
Students 18 & under $5.00…………………………………
Family membership $25.00……………………….
Lifetime individual membership $100.00………………….
Additional adult lifetime membership $50.00……………….
Lifetime family membership (includes: partners and all children & future children under the age of 18) $250.00…………………………..
Business membership $100.00 . . . . . . . . . . . . . . . . . . . . .
Single-Payment Dues Level ():
I wish to make an additional donation of . . . . . . . . . . . . . . . . . . . . . .
Benefactor Level: () . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bronze Benefactor $250.00 Silver Benefactor $500.00
Gold Benefactor $1,000.00 Platinum Benefactor $5,000.00
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please Make your check payable to Collins Regional Historical Society
EXPLANATION OF TERMS
The qualifications for membership in the Collins Regional Historical Society (hereinafter the “Society”) are:
(a) An interest in the history of the Collins Region, and (b) A desire to further the purposes of the Collins Regional Historical Society.
The following information refers to items on the Society’s membership application.
Personal Information
Please complete the personal information at the top of the form. This information will be used to record your membership and will be listed in the same manner in the Society’s Membership Roster. The Society will not share the information you furnish us with any unrelated third party.
Interests
The information you provide about those topics and activities in which you have interest will be used to guide the Society in planning its programs. You may also be invited to join a particular committee that is concerned with one of the interests you indicate.
Membership and Dues
Individuals may become regular members by paying dues of $10.00
Other adult individuals in a regular member’s immediate family and living at the same address may become members by paying an additional $5.00 each.
Businesses that join for $100.00 may designate any individual to represent their business at meetings.
Individuals may become Life Members by making a one-time irrevocable donation of $1,00.00, which exempts them from paying dues for the rest of their life. Life Members are designated as Life Members in the Society’s Membership Roster.
Additional Donations
Additional donations from Members are gratefully accepted at any time.
Benefactors
Those members who wish to make a Benefactor Donation to the Society will be recognized as a Benefactor of the Society in the year the donation is made, and will be designated as a Benefactor at the appropriate level in the Society’s Membership Roster in the year following the donation. A member’s cumulative additional donations that reach a level of Benefactor Donation in a calendar year will be treated as one Benefactor Donation.
Tax Deductibility
The Society has applied to the Internal Revenue Service for recognition as a charitable organization under Section 501(c) of the Internal Revenue Code. A similar application has been made to New York State.
When such recognition is granted, any contributions that have been made to the Society since its inception will be deemed to be tax deductible for Federal and New York income tax purposes.
The goods or services provided to members and donors to the Society meet the standards for "insubstantial value" set out in Revenue Procedure 90-12, 1990-1 C.B. 471, and Revenue Procedure 92-49, 1992-1 C.B. 987 (as updated); therefore contributions (including membership dues) to the Society are wholly deductible for Federal and New York State income tax purposes unless otherwise indicated.