Membership Form

I/We wish to support the Putnam County Museum.
With our tax-deductible gift we are helping to preserve and share our unique local heritage.

Mr.___   Mrs.___   Ms.___   Mr. & Mrs.___   Dr.___
Name: _______________________________________
Spouse Name: _________________________________
Address:______________________________________
City: _________________________________________

State: _____________  Zip:_______________________
Phone: _______________________________________
E-mail: _______________________________________

Please check your level of membership:

___ Student $10

___ Collectible $25-$49

___ Keepsake $50-$99

___ Artifact  $100-$249

___ Antique $250-$499

___ Treasure $500-$999

___ Heirloom $1000-$4000

___ Partner $5000 and up

You can pay by cash, check, or charge.  If you pay by charge, we accept MasterCard and Visa. 

Please fill out the following information:

Amount Charged: _______________________________

Credit Card #: __________________________________

Expiration Date: ________________________________