Sustaining Society Pledge Form

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Name*
First Last
Please list my name(s) on your donor lists as:
Please recognize this gift in honor, or in memory, of:
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email Address*
I would like to join the Sustaining Society!
Please select your preferred level of support:
- Ambassador: $500+ a year for 5 years
- Patron: $1,000+ a year for 5 years
- Benefactor: $5,000+ a year for 5 years
- Philanthropist: $10,000+ a year for 5 years
If you choose not to join the Sustaining Society at this time, but still want to support the Museum of Art with an annual pledge:
Annual Pledge Amount $ Annual Payment of Pro-Rated Monthly? Number of Years Pledged
Preferred Payment Schedule*
- One payment charged annually on October 30
- Pro-rate my annual gift to be charged monthly on the 10th of every month
Payment Method*
- Visa
- MasterCard
- American Express
Credit Card Number*
Expiration Date*
mo / yr
Card Verification Code*
The CVV/CVC code (Card Verification Value/Code) is located on the back of your credit/debit card on the right side of the white signature strip
Confirmation*
I agree to the above pledge conditions.
Phone
This field is for validation purposes and should be left unchanged.

Annual Pledge Amount $	Annual Payment of Pro-Rated Monthly?	Number of Years Pledged