Grayson County, Virginia Heritage Foundation
P.O. Box 679
Independence, Virginia 24348

Please complete this form, print and mail it along with a check to the address above.

Date: ________________________ Select one: New ____ Renewal ____

Please select the type of membership you want:
–Regular ($25.00 US) ___ Student (under 20 years old) ($10) ___
–Organization (non-voting) ($45) ___ For-profit business (non-voting) ($50) ___
Dues are for a one year from date of receipt.

Name: ___________________________________
Address (line 1): ____________________________
Address (line 2): ____________________________
City: ________________________________________ State: _____Zip: _________________

Telephone: ____________________________ E-mail: ____________________________
To save costs we would like to use your e-mail and our Internet web site for regular communications.
_____ Yes, use my e-mail address. _____ No, please use my mailing address

The Grayson County, Virginia Heritage Foundation intends to publish its membership list and families being researched in an annual publication to members. Please indicate whether or not you give permission to publish your name. Unless you specifically request not to be listed, your name will be published.
_____ Yes, I give permission to publish my name and address in the membership listing.
_____ No, I would rather you do not publish my name and address in the membership listing.

I am interested in the following aspects of Grayson heritage. (If family history please include up to eight surnames.)
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