The Modern Contemporaries
                                  Membership Form

                         Modern Art Museum of Fort Worth    
              3200 Darnell Street                Fax (817) 840-2106                  
              Fort Worth, TX 76107               Phone (817) 738-9215
                                         
                                       
                            Join/Renew The Modern Contemporaries
        
________ Individual $100.00                  ________ Couple  $150.00


                            Already A Current Modern Member
							
					
________ Individual  $50.00                 ________ Couple $100.00


                                  Modern Contemporaries Gift

 ________ Individual $100.00                  ________ Couple  $150.00
 
 
Member's Information:

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

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

Name _______________________________________________________

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, 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 __________________________________________________



GIFT MEMBERSHIP INFORMATION:

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) _____________________

Personal Message: (To be included in gift card):