Name: ______________________________________________________

Address: ___________________________________________________

Phone: __________________ Email: _______________________________

Please print out this application and return with your check or credit card information to:

Moravian Historical Society
214 East Center Street
Nazareth, PA 18064

My total membership payment is enclosed (please make check payable to the Moravian Historical Society)

Please charge my membership to my credit card.
___ Visa     ___ MasterCard    
Account Number: ____________________   Exp. Date: ______________
Code: _______
Signature: ____________________________________________________

I wish to pay in quarterly installments. Enclosed is my first payment. (The Society will send me a reminder for the next 3 payments.)

Membership will be activated n the month following receipt and will be vaild through September 30, 2012.