Order of Confederate Rose
Chapter #1
Membership Application
Address____________________________________________________________________________________
___________________________________________________________________________________________
City________________________________ State_____ Zip Code________________________
E-Mail Address______________________________________________________________________________
Date of Birth________________________________ Mark One _______ Lady _______Gentlemen
Tell us about your interests, tasks or talents and why you are interested in joining_________________________
__________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Mark your choice of membership
______________ Chapter Member ____________ Member at Large __________Lifetime
Applicant's Signature___________________________________________________ Date__________________
Please print and return completed application to:
Mary Beth Sills
9671 Mt Hope Rd
Thornville, Ohio 43076
Please note we have not decided upon a dues structure yet.