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The House of Sellassie Historical Society
APPLICATION FORM
for 1999-2000 Membership
NOTE: Annual membership is $10/person.
Membership period is January 1 - December 31
NEW MEMBERS!
Please complete a form for each person applying for membership:
This form should be printed, completed and mailed to 115 Kelsan Way Fairbanks AK 99709 USA
Make all checks payable to The House of Sellassie Historical Society - MembershipThe House of Sellassie is a cultural organization without political or religious affiliations. Read about the Members' benefits in Sellassie Newsletter (electronic form only).
Name: _________________________________________________________________ Address: ______________________________________________________________ City: _________________________________ State__________ Zip __________ Telephone No. _________________________________________________________ (include area code)______ Check here if you would like your name included in the Membership Directory.
_______ Enclosed is a donation of $ ______________
CONTACT PHONE: 907/455-6149
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@2000 house of sellassie