Name_________________________________________________________________________________




Address______________________________________________________________________________




City____________________________________________________________State_________________________



Zip _____________________________________________




Phone No.______________________________Email ________________________________________



$20.00 paid by _______check   _______cash

The Piedmont Historical Society would like to include in future quarterlies a list of

surnames being researched by members. This list should include information about the

researching member so contacts can be made. If you would like for your name and list

of surnames/persons you are researching to be included in our publication, please

complete the following. We must have your signature of consent for publication of your

name and information before we can include your list. As you complete the form below,

please include only the information you wish us to publish.


Name:_______________________________________________________________________________


Mailing Address:_____________________________________________________________________


Telephone:__________________________________ Email:__________________________________

NAMES RESEARCHED (please print-limit to 10 names)


__________________________________________  __________________________________________


__________________________________________  __________________________________________


__________________________________________  __________________________________________


__________________________________________  __________________________________________


__________________________________________  __________________________________________


Signature of consent to publish:_______________________________________________________


Print name:____________________________________________________________________________