MELUNGEON HISTORICAL SOCIETY, INC.
Membership Form
Print and complete the membership form and mail with your dues payment to
Becky Nelson
MHS Secretary/Treasurer
2200 Hawkins St.
Knoxville, TN 37921

Name:_________________________________ Phone Number:____________________
Address:________________________________________________________________
City: __________________State: ______ Zip: ________Country: __________________

E-Mail address: ___________________________________
Web site or blog address: ___________________________________________________

Are you a Melungeon descendent or Melungeon related?
If you are a Melungeon descendant would you please list your known Melungeon Ancestors, if you are Melungeon related would you please list some of your Melungeon related Ancestors?

Melungeon Ancestors:_____________________________________________________
________________________________________________________________________
Melungeon Related Ancestors:_______________________________________________
________________________________________________________________________

Membership levels and dues:
___ Individual Memberships, $12.50 per year
___ Lifetime Membership, $125
___ Sponsored Membership
___ Gift Membership, I am sponsoring this applicant, my information is:

Name:_____________________________ Phone number:________________________
Address: ___________________________City: _____________State_____ Zip_______
E-mail address: __________________________________________________________

This application will be reviewed by our Membership Committee, and upon acceptance and dues paid, you will be entitled to newsletters, the latest information on Melungeons, a list serve chat group, discounted or no fees for programs, voting and nominations for the 2 at-large members of the board. Dues will be due at 1 year intervals. (Check or money order only, payable to MHS. Please do not send cash.) If your application is not accepted, your check/money order will be returned. You are encouraged to send documented charts of Melungeon family lines, on which you can furnish data along with your application. Data submitted will become the property of the society for the intent of publication.

Signature:_____________________________________ Date:__________