Membership/Gift Form


Yes, I would like to help support the Eastland Disaster Historical Society.

Member senior ($40)
Member basic ($50)
Contributor ($100 - $249)
Donor ($250 - $499)
Supporter ($500 - $999)
 
Georgiana Becker Fellowship
Sustainer ($1,000 - $2,499)
Sponsor ($2,500 - $4,999)
Patron ($5,000 - $9,999)
Benefactor ($10,000+)

Other $

Salutation

First name

Last name

Spouse name

Street address

 

City

State/Province

Zip/postal code

Home phone number

Work phone number

E-Mail address

PAYMENT INFORMATION
Personal check Cashiers check Money order
VISA MasterCard

CREDIT CARD INFORMATION
(if paying by VISA or MasterCard)
Account number
Expiration date
 
Card authorization number
(last 3 or 4 digits on reverse side of card)
Name (as it appears on credit card)
Address

City
State
Country
Postal code
Type in the information above and print this form.  Then phone, fax or mail form and payment to:
Eastland Disaster Historical Society
P.O. Box 2013
Arlington Heights, IL  60006-2013
1-877-865-6295 (phone)
1-877-865-6295 (fax)


We accept personal checks, cashiers checks, money orders, VISA and MasterCard.