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BURPEE MUSEUM MEMBERSHIP
INSTRUCTIONS:
Use your browser's "PRINT" button to
print this page. Please return the form to the Information Desk at the
Burpee Museum, or mail it to:
Burpee Museum, Attn: Membership
737 North Main Street
Rockford, IL 61103
Your membership to Burpee Museum is tax deductible under the fullest extent allowed by law. Consult your tax advisor.
This membership is for: |
________________________________________________ |
Address: |
________________________________________________ |
| ________________________________________________ | |
City, State, Zip: |
________________________________________________ |
| Telephone: | ______________ E-mail: ____________________________ |
If this membership is a gift, the giver is: |
________________________________________________ |
Address: |
________________________________________________ |
| ________________________________________________ | |
City, State, Zip: |
________________________________________________ |
| □Individual / Single Parent $50 (2 year $90) | □Family $60 (2 year $110) |
| □Grandparents $60 (2 year $110) |
| □Hell Creek Society $1000 (2 year $1800) |
I would also like to support the Burpee Museum with my
contribution of $______________
Total
Amount Enclosed: $_______________________
Payment: □ Check payable to Burpee Museum
□
Visa/MC #_____________________________ Exp _____________
Signature: ___________________________________________________________