The Capitol Dome

Summer 2012

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YOUR INFORMATION Name(s): Street Address: City: E-mail: RESPONSES READER Complete the appropriate sections of State: CHECK ALL THAT APPLY: u NewMembership u Event Registration Zip Code: u Membership Renewal u GiftMembership u Marketplace Order u Volunteering LEVEL OF MEMBERSHIP u $35-$49 Charter Member u $250-$499 Rotunda Society Freedom Society u $500-$999 u $50-$99 Architect of History u Please record me as a Capitol Alumni Member* DOME MARKETPLACE Item Number Cornerstone Society u $1,000-$4,999 u $100-$249 Capitol Circle Complete form and fax to (202) 544-8244. Or call toll-free at (800) 887-9318. Quantity Unit Price Extended Price EVENT REGISTRATION: List the events that you wish to attend. Include your name(s) and a phone number at which we may contact you. $2000 $2000 $3000 $4000 or less SHIPPING AND HANDLING $5000 to $3000 to $4000 to $5000 $6.95 $8.95 $10.95 $12.95 $7500 to $7500 to $10000 $16.95 $19.95 MORE THAN $100.00 $24.95 PLEASE ADD $2500 SHIPPING FOR EACH FRAMED PRINT. FOR PACKAGES OVER 25 LBS., ADD $10 PER ADDITIONAL 10 LBS. METHOD OF PAYMENT u Enclosed is a Check orMoney Order payable to: U.S.Capitol Historical Society u I am paying by Credit Card (please circle one): VISA MC AMEX DISCOVER CARD # Cardholder Signature (required): Expiration Date: SUB-TOTAL: SHIPPING: MEMBERSHIP: TOTAL DUE: You may fax this form to (202) 544-8244 or mail it to: USCHS, 200 Maryland Ave., NE Washington, DC 20002-5796 Questions? Call toll-free (202) 543-8919, ext. 10. (800) 887-9318 For local calls, YES, I/WE WILL ATTEND: *CAPITOL ALUMNI MEMBERSHIP: The Society recognizes the service of individuals, family members and descendants of those who have served in the U. S. Congress. Our Capitol Alumni members represent the living history that USCHS is charged to preserve. To become a Capitol Alumni Member, please tell us your connection with the Capitol. this page to enroll as a Society member, renew your membership, give a gift membership, or order items from The DomeMarket Place. If you are giving a gift membership, please provide the person's name and address below. GIFT MEMBERSHIP:

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