Print and fill out form and send it with your payment to:
Lauren Rogers Museum of Art • P.O. Box 1108 • Laurel, MS 39441

    Lauren Rogers Museum of Art
    Membership Application

    I want to join the Lauren Rogers Museum of Art.
    Please enroll me in the category checked below.

 □ Laureate ($2500)
 □ Sustaining Benefactor ($1,500)
 □ Grand Benefactor ($1,000)
 □ Benefactor ($500)
 □ Donor ($250)
 

   □ Patron ($150)
   □ Sponsor ($100)
   □ Friends ($50)
   □ Associate ($25)
   □ Student ($15)
 

    Name_______________________________________________
    Spouse's Name_______________________________________
    Address_____________________________________________
    City________________________ State_______ Zip_________
    E-mail Address_______________________________________
    Phone Number (Home) ___________  (Work)_____________

    Please send a gift membership to________________________
    Name________________________________________________
    Address______________________________________________
    City_________________________ State_______ Zip_________
    Amount of gift membership category $___________________
    Please sign gift card____________________________________

    □ Enclosed is my check payable to the
         Lauren Rogers Museum of Art

    □ Please charge my membership to:
        □ VISA          □ MasterCard
        Card Number _________________________  Exp._________
        Signature____________________________________________

    □ My company will match my gift
         Company Name______________________________________
    □ I have included the Lauren Rogers Museum of Art in my will
    □ I would like information about how to include the
         Lauren Rogers Museum of Art in my will

    Based on IRS guidelines, the full amount of your membership may not be
    taken as a tax deduction. Your membership acknowledgement will outline
    the amount of your deduction based on the fair market value of your
    membership benefits.
                                               ANY QUESTIONS?
                           Please call the Museum at (601)649-6374
                                 or e-mail aboone@lrma.org.