Name __________________________________________Class Year_________
Spouse _________________________________________Class Year_________
Address__________________________________________________________
City _____________________________________________________________
State _____________ Zip ____________ Telephone ______________________
E-mail____________________________________________________________
__Individual ($25) __Virginia Davis Society ($500)
__Family($50) __Georgia Morgan Society ($1000)
__Patron ($100) __ Pierre & Louise Daura Society ($2500)
__Curator’s Circle ($250)
__Renewal __New Member [Valid through June 30, 2009]
Other $__________________________________________________________
Gift in honor or memory of _____________________________________________
Honoree’s or Family's Name & Address____________________________________
__________________________________________________________________
(Gifts in honor or memory will not mention amounts in acknowledgements).
I will contact my employer to request a Matching Gift Form, which will increase the
impact of my gift. Employer _____________________________________________
Credit Card (MasterCard, VISA, Discover)
Account Number _____________________________________________________
Expiration Date ________________________Date of Gift _____________________
Signature of Card Holder _______________________________________________
Please return this form with your payment to:
Daura Gallery
Lynchburg
1501 Lakeside Drive
Lynchburg,
Gifts can be made safely online (MasterCard or VISA) at www.lynchburg.edu/GivingtoLC
Contributions to the Friends of the Daura Gallery are fully tax-deductible.