Key West Art & Historical Society
Membership Form
Enjoy the Privileges of the Society's General Membership

Please print, complete and mail this form to:

Key West Art & Historical Society
281 Front Street, Key West, FL 33040
305-295-6616 FAX: 305-295-6649

Check One: [ ] Mr.   [ ] Mrs.  [ ] Ms.

Name: ___________________________________________________________

Address: ________________________________________________________

Address2: _______________________________________________________

City: ____________________ State: ___________ Zip: ______________

Phone (Work): ___________________________________________________

Phone (Home): ___________________________________________________

Fax: ____________________________________________________________

E-Mail: __________________________________________________________

Please Indicate Membership Category:

General Membership

[ ] Individual $55

[ ] Dual $100

[ ] Family $125

[ ] Friend $250

[ ] Donor $500

[ ] Sustaining $1000

Business Membership

[ ] Business Sponsor $150

[ ] Business Partner $250

Make Check Payable to Key West Art & Historical Society

Or, Charge to your Visa, MasterCard, or American Express

Credit Card # ____________________________________________________

Expiration Date: _________________________________________________

Name as it appears on card: ______________________________________

Authorized Signature: ____________________________________________
___ I prefer not to receive any benefits that would reduce the tax-deductibility of my gift.

___ I have enclosed my company's matching gift form.