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Philippine National Historical Society

MEMBERSHIP FORM

 

Name _________________________________________________________________

Position (Rank/Title) _____________________________________________________

Affiliation ______________________________________________________________

(Institutional/Professional)

Mailing Address _________________________________________________________

_______________________________________________Zip Code ________________

Telephone (Office) ________________________ Fax _________________________

(Home) _______________________________________________________

E-mail _______________________________________________________

Date of Application/Renewal ______________________________________________

Membership

[ ] Regular/Student P 100.00 annually

[ ] Regular/Professional P 300.00 annually

[ ] Lifetime P 1,000.00

[ ] Institutional P 3,000.00 annually

Please return to:

Dr. Bernardita R. Churchill

President, Philippine National Historical Society, Inc.

40 Matiwasay Street, UP Village

Diliman, Quezon City 1101

E-mail: nitachurchill@hotmail.com

nitarc@i-manila.com

PNHS webpage: http://pnhsi.tripod.com

____________________________________

Signature