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The Coutts Memorial Museum of Art
110 N. Main, El Dorado, KS 67042
(316) 321-1212

MEMBERSHIP

Please print this page, complete the form, and mail the form along with your check to:
 

MEMBERSHIP FORM
Coutts Memorial Museum of Art, 110 N. Main
El Dorado, KS 67042-0001

_____ Yes, I want to support this unique and valuable asset in my community. (Your gift is tax deductible!)
Name:_________________________________________Telephone:______________________
Address:_______________________________________________________________________
City:___________________________________________State:_____Zip:__________________
E-mail:________________________________________________________________________

Membership Levels: Membership gift prints for memberships of $50 or greater level, while supply lasts. One print per family.

_____Single, $25 _____Couple, $50
_____Patron, $50
_____Underwriter, $100 - $499
_____ Benefactor, $500 & above
Payment Options:
______Check (payable to Coutts Museum) _____Credit Card
Name on Card____________________________________ MasterCard, Visa, Discover (Circle one)
Card #__________________________________________ Expiration Date___________________
Cardholder Signature_______________________________________________________________

Consider purchasing a GIFT MEMBERSHIP for employees, co-workers, or that hard-to-buy-for friend or relative. We will send them a special notice stating you have made this gift membership in their name and also send them their FREE gift print. What a great Christmas or anytime gift!

Name_________________________________________Telephone Number___________________________
Address_________________________________________________________________________________
City_______________________________________State_____Zip______________________________
Level:_____Single_____Couple_____Patron_____Underwriter_____Benefactor_____


because it works!