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

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.

Salutation
First name
Last name
Spouse name
Street address

City
State/Province
Zip/postal code
Home phone number
Work phone number
E-Mail address