The Millet and District Historical Society
C/o Millet and District Museum and Exhibit Room
P.O. Box 178 5120-50 Street
Millet, Alberta Canada

T0C 1Z0

Name: ______________________________________________

Address: ___________________________________________ 

____________________________________________________

Daytime Phone: (_____)______________________________

E-mail: ____________________________________________ 

Payment Enclosed by cheque or money order $_____.___ 

Please send me a tax-deductible receipt for my donation of $ __________ over and above the membership fee.

Please make cheques payable to the Millet and District Historical Society. Please print this form and mail it to the above address.

Thanks!