MacNider Art Museum, a North Iowa treasure


	membership form

Print this form, complete it, and send it with your contribution to:

Charles H. MacNider Art Museum
303 Second St SE
Mason City, IA 50401

Charging your membership? Just phone 641-421-3666 or fax your information to 641-422-9612.

Please check one of the following levels:

General Membership:

[_] College Student: $25

[_]Individual Patron: $30-99

[_] Household Patron: $40-99

Masterpiece Membership:

[_] Bronze Patron: $100-249

[_] Silver Patron: $250-499

[_] Gold Patron: $500-999

[_] Platinum Patron: $1000 & up

Business Membership:

[_] Business Patron: $75-499

[_] Bronze Partner: $500-999

[_] Silver Partner: $1,000-1,999

[_] Gold Partner: $2,000-2,999

[_] Platinum Patron: $3,000 & up

[_] New [_] Renewal [_] Gift Membership

[_] Ms. [_] Miss [_] Mrs. [_] Mr. [_] Mr. & Mrs. [_] Other

_______________________________________________
Name (as you wish it to appear on publications)
_______________________________________________
Address
_______________________________________________
City, State, Zip
_______________________________________________
Phone (Home) (Business)
_______________________________________________
Email

Membership $ ___________
+ Studio Fee $ ___________
Total Amount $ ___________

[_] My enclosed check is made payable to the MacNider Art Museum

Please charge $ ______________
[_] VISA [_] Mastercard [_] Discover Card
Acct. # _________________________________________
Acct. Name _____________________________________
Expiration Date __________________________________
Signature _______________________________________

My company, _____________, has a matching gift program.
[_] Form is enclosed. [_] Form will be mailed. [_] Form will be faxed.

Contributions beyond fair market value of membership benefits received are tax deductible.

Giving a Gift Certificate?

Send gift announcement to: [_]Recipient [_] Me
Send renewal notice to: [_] Recipient [_] Me
Sign gift card: ____________________________________

Return to the MacNider Web site.