OSAGE SHAREHOLDERS ASSOCIATION         

P. O. Box 418         

PAWHUSKA, OKLAHOMA 74056         

 
 

____________________________________________________________________________

  
     
 

MEMBERSHIP /  RENEWAL / REINSTATEMENT APPLICATION         

 
 

Please provide the below information along with your check or money order payable to the above address for a

 
  ONE  YEAR MEMBERSHIP and SUBSCRIPTION to the O.S.A. QUARTERLY NEWSLETTER. Please check  
  the membership that applies to you. THANK YOU FOR YOUR MEMBERSHIP & SUPPORT.  
  .  
  __SHAREHOLDER MEMBERSHIP:

$35.00

 (Osages RECEIVING Osage Headright Income)  
  __ASSOCIATE MEMBERSHIP:

 

$10.00

 (Osages NOT RECEIVING Osage Headright Income)  
     
 

MMEMBER'S NAME: ______________________________________________________________________

 

  
  ADDRESS: ____________________________________________________________________________  
     
 

C CITY ___________________________________ STATE:  ___________ ZIP: _______________________

 

  
 

.

  
  TELEPHONE_____________-______________-__________________E-MAIL ______________________  
  ____________________________________________________________________________  
     
 

**PLEASE DO NOT WRITE IN THIS SPACE. O.S.A. USE ONLY**

  
  Date Received O.S.A. _____________ Membership Card Mailed: _____________ Disk:_____________  
 

Expiration Month/Year:_________ Type Payment:  _____ Check    _____ Money Order   _____ Cash

  
     
     
    .
  =================================================================================  
     
 

OSAGE SHAREHOLDERS ASSOCIATION         

P. O. Box 418         

PAWHUSKA, OKLAHOMA 74056         

 
 

____________________________________________________________________________

  
     
 

MEMBERSHIP /  RENEWAL / REINSTATEMENT APPLICATION         

 
 

Please provide the below information along with your check or money order payable to the above address for a

 
  ONE  YEAR MEMBERSHIP and SUBSCRIPTION to the O.S.A. QUARTERLY NEWSLETTER. Please check  
  the membership that applies to you. THANK YOU FOR YOUR MEMBERSHIP & SUPPORT.  
  .  
  __SHAREHOLDER MEMBERSHIP:

$35.00

 (Osages RECEIVING Osage Headright Income)  
  __ASSOCIATE MEMBERSHIP:

 

$10.00

 (Osages NOT RECEIVING Osage Headright Income)  
     
 

MMEMBER'S NAME: ______________________________________________________________________

 

  
  ADDRESS: ____________________________________________________________________________  
     
 

C CITY ___________________________________ STATE:  ___________ ZIP: ______________________

 

  
 

.

  
  TELEPHONE_____________-______________-__________________E-MAIL _____________________  
  _____________________________________________________________________________________  
 

**PLEASE DO NOT WRITE IN THIS SPACE. O.S.A. USE ONLY**

  
     
  Date Received O.S.A. _____________ Membership Card Mailed: _____________ Disk:_____________  
 

Expiration Month/Year:_________ Type Payment:  _____ Check    _____ Money Order   _____ Cash