Below is my name and address:

My phone number is:

Method of payment:

____Enclosed is my check

____Please charge my
___Visa ___ Mastercard

Account # ___________________

Exp. date _____________

Signature ____________________

I wish to join at the following level:
Founder $100 ____
Historian $ 75 ____
Archivist $ 50 ____
Pioneer $ 25 ____
Postmaster $ 15 ____
Other $_____ ____

Remember -- Your total donation is tax-deductible!

Please print out this form and send it with your payment to:

The History Museum for Springfield-Greene County
830 Boonville Ave.
P.O. Box 8368
Springfield, MO 65801