Membership Information

Title:	Select one Mr. Mrs. Ms. Dr.
Name:
Address:		Day phone:
Address 2:		Evening phone:
City:		State: AK AL AR AZ CA CO CT DC DE FL GA HI IA IL IN KS KY LA MA MD ME MI MO MN MS MT NC ND NE NH NJ NM NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip:

Yes! I'd like to receive email updates about the Society's programs. Email address:

This is a gift membership. Please send renewals to: giver recipient

Giver's name:
Address:		Day phone:
Address:		Evening phone:
City		State: AK AL AR AZ CA CO CT DC DE FL GA HI IA IL IN KS KY LA MA MD ME MI MO MN MS MT NC ND NE NH NJ NM NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip:

Select Membership Level:

Basic -$40
Student-$30
Senior-$30
Gaspee-$50-$99	Specify Amount: ($50-$99)
May 4th-$100-$249	Specify Amount: ($100-$249)
Roger Williams-$250 & up	Specify Amount: ($250 & up)
Lifetime-$2000

Method Payment: Credit card Visa Mastercard American Express Credit Card account number:

Name on card:

Expiration date:

Check Cash

You cannot submit a membership online at this time, but you can print and mail this form with payment.

Mail to: RIHS Membership Office, 110 Benevolent Street, Providence RI 02906

Questions? Email the Membership Office. Or call (401) 331-8575 x33

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