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Registration Form

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Henry S. Olcott Memorial Library
User Registration Form

Name: _______________________________________________________________

Address: _____________________________________________________________

City: _________________________________ State: _________ Zip: ___________

Phone: _______________________________ e-mail: ________________________

I am currently a member of the Theosophical Society in America. Yes ____   No____
Members of the Theosophical Society in America who are residents of the United States receive free library privileges as part of their membership.

I agree to the borrowing conditions of the library and accept responsibility for the materials checked out in my name.

_____________________________
Signature		 ________
Date

 

Life Library membership   $150

 

$ _____._____
One-year Library membership
      Local borrowers $30 $ _____._____
      Mail borrowers $40 $ _____._____
 

Total payment included

 $ _____._____

 Credit card information

__ Visa    __ Mastercard    __ Discover

_____________________________________ ___________      
Credit card number                                               Exp. date

3-digit Verification Code (located on back of the card)______

_____________________________________
Signature

Mail or fax this completed form with payment to:

Henry S. Olcott Memorial Library

 

P. O. Box 270
Wheaton, IL 60187-0270
Fax 630-668-4976