Application Form - Lincoln Highway Association

Print out this page, fill it out the application, and mail it to:

Lincoln Highway Association — Treasurer
P.O. Box 1326
Delaware, OH 43015

Date: ____________________ Annual membership is from date of enrollment.

( ) New Membership ( ) Renewal

Membership Categories:

( ) Student:* $25
( ) Individual: $45
( ) Family: $60

( ) Libraries, museums & historical societies: $45
( ) Local, state, and county governments: $45
( ) Supporting: $75

( ) Patron: $150
( ) Business: $75

( ) Corporate: $150
( ) Life: $1000 and up

* Students: include copy of front and back of student ID card

State Affiliation

Members who live in Lincoln Highway states are automatically members of that state's chapter. Dues for additional chapter memberships are $9.00 per year per state. Check the appropriate box.

[ ] NY
[ ] IN
[ ] CO

[ ] NJ
[ ] IL
[ ] UT

[ ] PA
[ ] IA
[ ] NV

[ ] WV
[ ] NE
[ ] CA

[ ] OH
[ ] WY

Please Print

Name	____________________
Address	____________________
City	_________	State	__	Zip	_____

Home phone	(__) ___________
Work phone	(__) ___________
E-mail address	______________

The Lincoln Highway Association is exclusively charitable and educational, within the interpretation of Section 501(c)(3) of the Internal Revenue Code.

Payment Method:

( ) Check (payable to Lincoln Highway Association)

Credit card: ( ) Visa ( ) MasterCard ( ) Discover

Name on card (if other than above):	________________
Address on card (if other than above):	________________
Card number (16 digits):	________________
CVV code (What is my CVV code?):	_____
Expiration Date:	___ / ___
Signature:	________________