YOUR INFORMATION
Name(s):
READER
RESPONSES
E-mail:
Street Address:
City:
State:
Zip Code:
CHECK ALL THAT APPLY:
q New Membership
q Event Registration
q Membership Renewal
q Marketplace Order
q Gift Membership
q Volunteering
LEVEL OF MEMBERSHIP
q $35-$49
q $50-$99
q $100-$249
Charter Member
Freedom Society
Cornerstone Society
q $250-$499
q $500-$999
q $1,000-$4,999
Rotunda Society
Architect of History
Capitol Circle
q Please record me as a Capitol Alumni Member*
Complete form and fax to (202) 544-8244.
Or call toll-free at (800) 887-9318.
DOME MARKETPLACE
Item Number
Quantity
Unit Price
Complete the appropriate sections of
this page to enroll as a Society member,
renew your membership, give a gift
membership, or order items from
The Dome Market Place.
If you are giving a gift membership,
please provide the person's name and
address below.
GIFT MEMBERSHIP:
*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.
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.
SHIPPING AND HANDLING
$5000 to $7500
$16.95
less
$6.95
$7500 to $10000
$19.95
$3000 $8.95
MORE THAN $100.00 $24.95
$4000 $10.95
$5000 $12.95
PLEASE ADD $2500 SHIPPING FOR EACH FRAMED PRINT.
FOR PACKAGES OVER 25 LBS., ADD $10 PER ADDITIONAL 10 LBS.
$2000 or
$2000 to
$3000 to
$4000 to
SUB-TOTAL:
SHIPPING:
MEMBERSHIP:
TOTAL DUE:
METHOD OF PAYMENT
q Enclosed is a Check or Money Order payable to: U.S.Capitol Historical Society
q I am paying by Credit Card (please circle one):
VISA MC AMEX DISCOVER
CARD #
Cardholder Signature (required):
YES, I/WE WILL ATTEND:
Expiration Date:
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
(800) 887-9318
For local calls,
(202) 543-8919, ext. 10.