Membership Form – print and complete

Prairie Aviation Musuem

Membership Application

Name ____________________________________________________________________

Address ___________________________________________________________________

City __________________________________________________________ State __________ ZIP _________________

Home Phone _(____ )______________________________­­­­­­­__ Cell _(_____)_____________________________________

Email _____________________________________________________________________________________________

Membership Levels 

__________ Individual ($30 annually)                                __________ Sustaining ($50 annually)

__________ Benefactor ($100 annually)                            __________ Youth under age 18 ($15 annually)

__________ Life ($1000)

__________ Family – 1 or 2 adults  & children 17 and under living at the same address  ($60 annually)

Method of Payment

______ Check (payable to Prairie Aviation Museum)

______ Visa  ______ MasterCard

Card #  __ __ __ __ – __ __ __ __ – __ __ __ __ – __ __ __ __  Expiration Date   Mo _____________ Yr ___________

Signature ________________________________________________________

Date _______________________________

Due to privacy laws, this information will not be used by anyone outside of the Museum.

Prairie Aviation Museum is a not-for-profit charitable organization under 501(c)(3) of the Federal Internal Revenue Code.  Donations to the Museum may qualify as tax-deductible gifts.

After completing this form, please mail it to:

          Prairie Aviation Museum

          % Tom Kuhn

          2929 East Empire Street

          Bloomington, IL  61704

Membership form 020814 – 2