I would like to purchase the following:

Date _____________________________

Publication Name(s): __________________________________      $________

Research Request Fee: $___________ (Please include request form)

Other ________________________________________________ $________

Name: ____________________________________________

Address: _______________________________________________________

Phone: _____________________________Email: _______________________(optional)

Method of Payment:

Check enclosed payable to The Anoka County Historical Society _____

Or charge to:   ___MasterCard     ____Visa

Account#:  __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Expiration Date:  __ __ Mo.  - __ __ Yr.

Signature: ______________________________________________________________