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Full name as it is to appear
on certificate,
print or type all information |
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Full
Name: |
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Address: |
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City/State/Zip: |
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Phone: |
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E-Mail: |
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Ancestor of the applicant proven
to have settled within Wythe County, Virginia on or before December 31,
1810. |
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Name of Ancestor |
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Year Settled |
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Ancestor Came from
(if known) |
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I understand that upon submission of my application,
including all supporting data and documents accompanying the
application, become the property of the Wythe County Genealogical and
Historical Association. |
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I , _________________________
do hereby swear/affirm that the statement set forth in this application
are true to the best of my knowledge and belief. |
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Signature of Applicant |
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Date: |
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Application fee: $20.00
Make checks or money orders payable to:
Wythe County Genealogical & Historical Association
P. O. Box 1601
Wytheville, VA 24382
website:
www.wythecogha.com
email:
wythecogha@gmail.com |
