Friends of the Daura Gallery Membership Form
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Friends of the Daura Gallery
Please return this form with payment to:
Daura Gallery
Lynchburg College
1501 Lakeside Drive
Lynchburg, VA 24501-3199
Name __________________________________________________Class Year_________
Spouse _________________________________________________Class Year_________
Address__________________________________________________________________
City _____________________________________________________________________
State _____________ Zip ____________ Telephone ____________________
Email________________________________@_______________________.____________
Please indicate whether you are renewing or new to the Friends of the Daura Gallery:
□ Renewal □ New Affiliate [Valid for 1 year]
Please check one of the following options:
□ Individual ($25) □ Virginia Davis Society ($500)
□ Family ($50) □ Georgia Morgan Society ($1000)
□ Patron ($100) □ Pierre and Louise Daura Society ($2500)
□ Curator's Circle ($250) □ Other Amount __________________
Gift in honor or memory of ______________________________________________________
Honoree's or family's name and address:
____________________________________________________________________
____________________________________________________________________
Payment Options:Payment Type: □ Credit Card (See below) □ Check □ Cash For credit card payments, please fill out the following information: Card Type: □ MasterCard □ VISA □ Discover Account Number _____________ /____________ /____________ /______________ Expiration Date ________ /________ Date of Gift _______ /_______ /_______ Signature of Card Holder ____________________________________________ |
□ I will contact my employer to request a Matching Gift Form, which will increase the impact of my gift. Employer Name _____________________________________________________
Gifts can also be made safely online (MasterCard or VISA) at www.lynchburg.edu/GivingtoLC
Contributions to the Friends of the Daura Gallery are fully tax-deductible. The Membership period runs from July 1 to June 30 each year.
