Albany Institute of History & Art
125 Washington Avenue

Albany, New York

12210
518-463-4478

information@

albanyinstitute.org

 

ENROLLMENT FORM

To become a member, simply complete the following form, print it and send it along with your contribution to:

 

Albany Institute of History & Art

External Relations Division

125 Washington Avenue

Albany, NY 12210

 

For questions or more information, contact the External Relations Division at 518-463-4478.
 

Please enroll me as a Member/Corporate Partner of the

Albany Institute of History & Art
My/Our membership is:  
    q New   q Renewing   q Gift   q Corporate Partner
Membership Categories (please check):
q $25 Student/Teacher q $125 Supporter
q $40 Individual q $250 Sponsor
q $60 Dual q $500 Sustainer
q $70 Family q $1000 Patron of the Arts
 
 

     q $1000   Corporate Partner

     q $ _____ Corporate Underwriter
Please indicate name(s) as it/they should appear on membership/gift membership card(s) and roster:
Mr./Mrs./Mr. & Mrs./Miss/Ms./Company Name:
_______________________________________
Mr./Mrs./Mr. & Mrs./Miss/Ms./Company Contact:
_______________________________________
Address:________________________________
___________________________________
___________________________________
City: ______________ State: ____ Zip:________
 
Daytime Phone: _________________________
Evening Phone: __________________________
Email address:___________________________

If this is a gift, AIHA will send a gift card and New member Packet announcing your gift.

 

Gift from: ____________________________________

 

Giver's Address: _______________________________

 

_____________________________________________

 

Giver's Phone: _________________________________

 

Message: _____________________________________

 

______________________________________________

 

 Please send gift notification to:

    q Giver                                 q Recipient

q Enclosed is a check or money order in the amount of  $_________ made payable to:

 Albany Institute of History & Art

OR
q Please charge the amount of $__________ to:
q Visa q MasterCard
q Discover q American Express
Card Number: _______________________________
Expiration Date:______________________________
Signature: ___________________________________

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