I (we) wish to be a member of the Washakie Museum to support the exciting exhibits, programs, and events.
Name of Person or Business: _____________________________________________________________________
Other names to be added to the Membership:_________________________________________________________
_________________________________________________________________________________________
Mailing Address:______________________________________________________________________________
_________________________________________________________________________________________
Phone:_______________________________ E-mail:________________________________________________
Membership Level: ___________________________Amount:______________
Name as it appears on the credit card:___________________________________________________________________________
Credit Card Type:___________________ #:________________________________________________________
Signature of Cardholder: ________________________________________________________________________
My membership is $300 or more please (circle one) bill me or charge my credit card (circle one) quarterly or semi-annual