FAMILY MEMBERSHIP: $75

INDIVIDUAL MEMBERSHIP: $55

HERITAGE SUBSCRIPTION: $35

This form is for Gift Memberships ONLY

This membership is

New
Renewal

Enter name of purchaser:

Address of Purchaser

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Where to send the gift membership:

To the below address
Send it to me and I will send out

Mail future renewal notices to:

Purchaser
Gift Recipient

Name

Prefix

First Name *

Last Name *

Suffix

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Phone

Membership

PA Heritage Foundation Membership

Member Type

Family Membership
Individual Membership
Heritage Subsciption

Second Adult Name

Second Adult Name and # of Children are for Family and Contributor Memberships

Prefix

First Name

Last Name

Suffix

# of Children for Family Membership:

Select a Payment Method

Credit Card
Bank Account

Cardholder Name

Credit Card #

Visa MasterCard American Express Discover

Expiration Date

Security Code

Cover the fee associated with this online transaction?

Yes, I will pay an additional {transaction_fee} to cover the cost of this transaction.

Cover the fee associated with this online transaction?

Account Holder

First Name

Last Name

Account Type

Checking
Savings

Account Holder Type

Personal
Business

Account Number

Routing Number

I authorize Pennsylvania Heritage Foundation to initiate, and my financial institution to honor, a one-time electronic debit from my bank account on the date, for the amount, and from the account listed.

Your total payment will be .

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Additional Comments

Membership Gift Form

Gift Membership Form