Circle of Friends Gift Membership

MIM is a registered 501(c)3 nonprofit organization.

Please complete the form below and click "Submit" to confirm your membership.

To submit this form, all "*" fields must be filled in.

Melody $1,000

Harmony $2,500

Curator's $5,000

Director's $10,000

Founder's $25,000

 

First Name*

Last Name*

Recognize me/us in donor listings as:

I wish to keep this gift anonymous.

Address*

City*

State* UNITED STATES Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming CANADA Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

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Email*

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PAYMENT INFORMATION

Payment Info

RECIPIENT INFORMATION

Primary First Name*

Primary Last Name*

Other First Name

Other Last Name

Address

Phone*

E-mail

Please DO NOT notify the recipient(s) about the gift membership.     It's a surprise!

ADDITIONAL INFORMATION

If you received a code, please select it here: None 2019DFSR 2019IA 2019LD 2019MMT GivingTuesday

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