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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!)
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Name:_________________________________________Telephone:______________________
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Address:_______________________________________________________________________
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| City:___________________________________________State:_____Zip:__________________ |
E-mail:________________________________________________________________________
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Membership
Levels: Membership
gift prints for memberships of $50 or greater level, while supply
lasts. One print per family.
| _____Single, $25 |
_____Couple, $50
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_____Patron, $50
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_____Underwriter, $100 - $499
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_____ Benefactor, $500 & above
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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_____
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