Gift Membership Form
							
To ensure delivery by December 25, gift membership applications must be submitted by December 18.

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

Membership level:                          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


This is a gift membership FROM:

____ Mr.   ____ Mrs.   ____ Miss   ____ Ms.  ____ Mr. & Mrs.  ____ Dr.  ____ Other

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

Name _______________________________________________________

Name 2 ______________________________________________________

Address ____________________________________________________

City/State/Zip _____________________________________________

E-mail address _____________________________________________

Telephone (home) ______________________  Telephone (work) _____________________


This is a gift membership FOR:

____ Mr.  ____ Mrs.   ____ Miss   ____ Ms.  ____ Mr. & Mrs.  ____ Dr.  ____ Other

Name _______________________________________________________

Name 2 ______________________________________________________

Address ____________________________________________________

City/State/Zip _____________________________________________

Telephone (home) ______________________  Telephone (work) _____________________

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.

To receive Family membership benefits, please list name and birth date of all children under 18 living at the same address:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

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 ____________________________________________________


Please send renewal notice for this gift membership to:

Me _________     Recipient _________

Mail gift membership packet to:

Me _________     Recipient _________

Mail membership packet:

Now ________     Later Date ________________________

Personal message (to be included on gift card): 

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________