NWHM Printable Gift Membership Form

______ I want to send a gift membership in the amount of:

____ $25 ____ $50 ____ $150 ____ $500 ____ Other

My check for $___________ is enclosed.

Please bill my American Express / MasterCard / Visa credit card:
Account #_________________________________ Exp. date ________________

Signature __________________________________________________________

Please print this form and mail it with your check (payable to NWHM)
or credit card information to:

National Women's History Museum
205 S. Whiting Street, Suite 254
Alexandria, VA 22304
tel: 703-461-1920
fax: 703-370-8287

My information:

____Mrs. ____Ms. ____Miss ____Mr. ____Dr.
Name ___________________________________
Address _________________________________
City _____________________________________
State ___________________________ Zip _________
Home Phone (______)___________________
E-mail __________________________________

This is a gift for:

____Mrs. ____Ms. ____Miss ____Mr. ____Dr.
Name ___________________________________
Address _________________________________
City _____________________________________
State ___________________________ Zip _________
Home Phone (______)___________________
E-mail __________________________________
(Please provide us with the recipient's email address so we can send them a notification of your gift.)