Membership Form
Membership Form General Levels
MEMBERSHIP LEVEL DESIRED:
PLEASE CHECK ONE:
Ambassador Levels
Dual ($100)
Sponsor ($210)
Family ($110)
Patron ($400)
Individual ($70)
Benefactor ($675)
Senior ($65)
New Membership
Renewal Membership No.
MEMBER INFORMATION:
Mr.
Mrs.
Ms.
Miss
Dr.
Other
NAME FIRST, LAS
NAME OF SECOND CARDHOLDER (for memberships at the Dual level and above)
ADDRESS
CITY
STATE
ZIP
HOME PHONE
CELL PHONE
EMAIL ADDRESS (for e-news)
CHILDREN'S NAME, AGE AND BIRTHDAY MONTH (for the Family level and above)
PAYMENT METHOD $
Membership Fee
$
Here is an extra gift because I love PEM (fully tax deductible)
$
Total
Check enclosed (payable to Peabody Essex Museum)
Charge to my credit card
ACCOUNT NO.
NAME ON CARD
Visa
MasterCard
American Express
EXP. DATE
SIGNATURE (required for credit card)
PLEASE MAIL FORM WITH PAYMENT TO: Membership Department Peabody Essex Museum 161 Essex St. Salem, MA 01970
Peabody Essex Museum | Membership Department | 161 Essex St. | Salem, MA 01970 | 978-542-1641 | [email protected]
MEMBERSHIP LEVEL DESIRED:
PLEASE CHECK ONE:
Ambassador Levels
Dual ($100)
Sponsor ($210)
Family ($110)
Patron ($400)
Individual ($70)
Benefactor ($675)
Senior ($65)
New Membership
Renewal Membership No.
MEMBER INFORMATION:
Mr.
Mrs.
Ms.
Miss
Dr.
Other
NAME FIRST, LAS
NAME OF SECOND CARDHOLDER (for memberships at the Dual level and above)
ADDRESS
CITY
STATE
ZIP
HOME PHONE
CELL PHONE
EMAIL ADDRESS (for e-news)
CHILDREN'S NAME, AGE AND BIRTHDAY MONTH (for the Family level and above)
PAYMENT METHOD $
Membership Fee
$
Here is an extra gift because I love PEM (fully tax deductible)
$
Total
Check enclosed (payable to Peabody Essex Museum)
Charge to my credit card
ACCOUNT NO.
NAME ON CARD
Visa
MasterCard
American Express
EXP. DATE
SIGNATURE (required for credit card)
PLEASE MAIL FORM WITH PAYMENT TO: Membership Department Peabody Essex Museum 161 Essex St. Salem, MA 01970
Peabody Essex Museum | Membership Department | 161 Essex St. | Salem, MA 01970 | 978-542-1641 | [email protected]
