NEW_______ RENEW _________ Address Change ___

NAME: ____________________________________________________

PHONE _____________

ADDRESS:_______________________________________________________

CITY: _____________________________________ STATE:___________

ZIP: _____________

E MAIL ADDRESS:____________________________

HOME PAGE URL _________________________________

Dues: Individual $12.00 Family $15.00 Make check payable to: BROOKE COUNTY GENEALOGY, INC. and mail this form to: P.O. Box 144 Beech Bottom, WV 26030-0144

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