Gift Membership Form

Gift Membership Form General Levels

MEMBERSHIP LEVEL DESIRED:

PLEASE CHECK ONE:

Ambassador Levels

c

Dual ($100)

c

Sponsor ($210)

c

Family ($110)

c

Patron ($400)

c

Individual ($70)

c

Benefactor ($675)

c

Senior ($65)



New Gift Membership



Gift Renewal Membership No.

GIFT RECIPIENT 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

CHILDREN'S NAME, AGE AND BIRTHDAY MONTH (for memberships at the Family level and above)

GIFT GIVER INFORMATION: 

Mr.



Mrs.



Ms.



Miss



Dr.



Other

YOUR NAME FIRST, LAS

ADDRESS

CITY

STATE

HOME PHONE

CELL PHONE

ZIP

EMAIL ADDRESS

Peabody Essex Museum | Membership Department | 161 Essex St. | Salem, MA 01970 | 978-542-1641 | [email protected]

Gift Membership Form

WE INCLUDE A GIFT CARD WITH EACH GIFT. PLEASE WRITE YOUR PERSONAL MESSAGE HERE:

SEND MEMBERSHIP GIFT TO:

c

Me

c

Recipient

SEND RENEWAL NOTICE TO:

c

Me

c

Recipient

PAYMENT METHOD

Membership Fee $

c

Check enclosed (payable to Peabody Essex Museum)

c

Charge to my credit card

c

ACCOUNT NO.

NAME ON CARD

Visa

c

MasterCard

c

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]