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| Her Majesty Queen Margrethe II of Denmark, Protector |
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| The Danish Immigrant Museum 2212 Washington Street P.O. Box 470 Elk Horn, Iowa 51531-0470 712.764.7001 © Since 1983; All Rights Reserved |
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| MEMBERSHIP FORM Print and complete this form; mail with payment to: The Danish Immigrant Museum Membership Department 2212 Washington Street P.O. Box 470 Elk Horn, Iowa 51531-0470 _________________________________________________________________________ Select a membership level: _______ Active Member - $30 _______ National Member - $50 _______ Contributing Member - $100 _______ Sustaining Member - $250 _______ Sponsoring Member - $500 _______ Benefactor - $500 _______ Patron - $1,000 _______ Business/Organization Associate (minimum $100) _______ Access to Heritage Quest Online (minimum $100 annual membership) _______ TOTAL (Include payment to "The Danish Immigrant Museum" for this amount.) Membership to The Danish Immigrant Museum makes a great gift. Please complete a separate form for each established membership. _________________________________________________________________________ Payment Information: [ ] A check or money order for $ _________ is enclosed. [ ] I authorize my credit card to be billed for $ _______________. MasterCard _______ Visa _______ Card # __________________________________ Exact Name On Card: ________________________________________________ Expiration Date: ___________ Signature: ___________________________________________ (Date) _________ The Danish Immigrant Museum is a 501 ( c) 3 non-profit organization. Your gifts and contributions are tax deductible to the extent allowed by law. Please contact your tax advisor. _________________________________________________________________________ Your Name: _____________________________________________________ Mailing Address: _________________________________________________ City: _______________________________ State: _________ ZIP: _________ Phone: ___________________________ E.Mail: _______________________ Please complete a separate form for each established membership. _________________________________________________________________________ Membership For: Same As Above: ___________ Member Name (When Different): _______________________________________________ Mailing Address: _________________________________________________ City: _______________________________ State: _________ ZIP: _________ Phone: ___________________________ E.Mail: ______________________ _________________________________________________________________________ For Office Use Only: Received By: _____________________ Initials: ________________ Date: ____________ |
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