Historical Museum of Southern Florida Graphic
 
11th Judicial Circuit Historical Society Registration Form
Please complete the form below and click the Submit button. Memberships for firms will be listed in the name of the firm. Individual memberships will be listed by the name of the member.

If you have any questions please call Member Services at 305-375-1619 or
e-mail 11JCHS@hmsf.org.
Primary Firm Contact/ Member
Salutation
First Name
Last Name
Suffix
Recognition
If different than first and last name, how do you wish to be recognized?
Ex. Mr. John Doe wishes to be recognized as Mr. Johnathan A. Doe
Home Email
Membership purchase confirmation will be sent here
Home Phone Ex. 3055551234
Home Address 1
Home Address 2
City State Zip
Date of Birth
The Museum will use birthdates
to qualify membership information 		Ex. MMDDYYYY
Firm Information
Firm/Organization Name     Your firm membership will be listed as shown here.
Business Address 1
Business Address 2
City State Zip
Business Email
Business Phone Ex. 3055551234
Please send correspondence to: Business Home
Please complete if this is a Gift Membership
Send Gift Membership to
On the occasion of
Recipient address
City State Zip
Recipient Phone Ex. 3055551234
Recipient E-mail
Gift Membership Given By:
Contact Name
Contact Phone Ex. 3055551234
Contact Email
   
Individual and Firm Membership Categories
Student $25 Public Service $75 Member $100
Associate $250 Patron $500 Partner $1,000
Heritage $2,500 Legacy $5,000 Charter $10,000
 
I wish to make a contribution to the 11th Judicial Circuit Historical Society in the amount of $

If you prefer to mail this form to us please print can complete and send with full payment to:

Development Office - 11JCHS
Historical Museum of Southern Florida
101 West Flagler St.
Miami, FL 33130-1504

Please make checks payable to: Historical Museum

For additional memberships, please photocopy this form.
For more information, call Membership Services at 305.375.1619 or fax 305.375.1609