Complete this form and submit it via secure email
Call 608 263-2246 or fax 608 263-8188 and we will mail you a form and return envelope
Complete this form, print it out and mail it with your check or money order

Membership Status	Give a Gift of Membership
Title
First name, Middle initial
Last Name
Spouse/Partner: Title
First name, Middle initial
Last name
Address
City, State	, Zip:
Country
Phone	Day: () Evening: ()
Email Address

I would like my name listed differently in the Chazen Museum Bulletin:

I graduated from the University of Wisconsin-Madison:
Graduation year:
Degree
Primary area of study

Membership Levels

	Director's Circle	$1,000
	Fellow	$500
	Associate	$250
	Founder	$125
	Patron	$75
	Family	$50
	Senior Couple (age 62+)	$40
	Individual	$35
	Senior (age 62+)	$25
	Student (full time) School: School ID no.: Grad. Date:
	I would like to make an additional gift

Matching Gift
You can double your contribution to the museum if your place of employment has a matching gift program. Check with your company's human resources office for a matching gift form.
Credit Card Number
Please enter the last three digits from the
signature box on the back of your card.

Expiration

Month:
Year:

If you would prefer to pay by check or money order, please print and mail this form to:

Chazen Museum of Art
800 University Avenue
Madison, WI 53706

608 263-2246