Membership Form

                         Modern Art Museum of Fort Worth    
              3200 Darnell Street                Fax (817) 840-2106                  
              Fort Worth, TX 76107               Phone (817) 738-9215
                                         
                                       
________ New               ________ Renew

Membership Levels:                         Discounted dues for Artists, 
                                           Senior Citizens, Students, Teachers:

________ Basic $50.00                      ________ Basic  $45.00

________ Associate  $100.00                ________ Associate  $90.00

________ Family $125.00                    ________ Family $112.50

________ Sustainer  $200.00                ________ Sustainer  $180.00

________ Contributor $500.00               ________ Contributor  $450.00

________ Individual Patron  $1000.00       ________ Individual Patron $900.00

________ President's Circle  $5000.00      ________ President's Circle  $4500.00

________ Chairman's Circle  $10000.00      ________ Chairman's Circle  $9000.00

________ Benefactor  $25000.00             ________ Benefactor  $22500.00

Corporate Membership Levels:

________ Corporate Patron $1500.00         ________ Corporate Patron $1350.00

________ Corporate Partner $5000.00        ________ Corporate Partner $4500.00

________ Corporate Benefactor $10000.00    ________ Corporate Benefactor $9000.00


Member's Information:

Prefix:  ___ Mr.  ___ Mrs.  ___ Miss   ___ Ms.  ___ Mr. & Mrs.  ___ Dr.  ___ Other

(Please specify if other prefix has been selected:) _____________________________

Name _______________________________________________________

Name 2 _______________________________________________________

Address ____________________________________________________

City/State/Zip _____________________________________________

Telephone (home) ____________________  Telephone (work) __________________

E-mail address _____________________________________________

_____Yes, I would like to receive monthly e-newsletters with information about events and programs.
 (The Modern does not sell or give e-mail addresses to other companies.)
 
 ____Yes, my company has a matching gift program. I will mail the form to the Modern.

Yes, I would like to make an additional contribution of $___________ to the annual fund in support of the 
Museum's exhibition and education programs.
Gifts to the annual fund are fully tax-deductible as permitted by law.

Method of Payment:

_______ Check enclosed made payable to the Modern Art Museum of Fort Worth

_______ Visa

_______ MasterCard

_______ American Express


Card Name __________________________________________________

Card Number ________________________________________________

Expiration Date ____________________________________________

Signature __________________________________________________