Name

Spouse

Address

City                      State          Zip
 
Telephone         Fax                E-Mail
 
Occupation

Special Interests

May we have your permission to include your telephone number and e-mail address in the LHA Membership Directory on the LHA web site (Password will be required for access) and also in the printed version? yes   no
Please note: This information will be used for official business of the LHA only.

Please list your Leftwich family line for the Association's genealogical records:

Parent:                         
Grandparent:                
Great grandparent:
G/G grandparent:
G/G/G grandparent:
G/G/G/G grandparent:
G/G/G/G/G grandparent:

Please list your children:

I would be interested in volunteering my services to the work of The LHA by serving on one of the following committees:

computer          ;                 research ;                       family census ;
family reunion ;              newsletter;                        membership  

Please enclose a check in the amount of $15.00 for annual dues made payable to The Leftwich Historical Association, Inc. and mail to:

Shirley Greer
The Leftwich Historical Association, Inc.

16522 Patrick Henry Hwy

Roseland, VA 22967