Image from the MMAC Permanent Collection: detail, Georges Rouault,
En Bouche Qui Fut Fraiche, 1948, Lithograph, 20.5 x 14 in
Image from the MMAC Permanent Collection: detail, Georges Rouault,
En Bouche Qui Fut Fraiche, 1948, Lithograph, 20.5 x 14 in
Image from the MMAC Permanent Collection: detail, Georges Rouault,
En Bouche Qui Fut Fraiche, 1948, Lithograph, 20.5 x 14 in
Yes! I/We want to be a member of MMAC!
Name(s): ________________________________________________________
Enclosed is my 2014-15
membership gift of:

$1,000 and above

$500 - $999
Email: __________________________________________________________

$250 - $499
PAYMENT INFORMATION

$100 - $249

$50 - $99

$25 - $49

$0, free!
Address: ________________________________________________________
City: __________________________ State: _________ Zip: _____________
(Champion)
Phone Number: ___________________________________________________


(Patron)
(Advocate)
Check Enclosed
American Express
(Visionary)

Visa

MasterCard

Discover
Card Number: ____________________________________________________
Expiration Date: _____________________ Auth. Number: ________________
Signature: _______________________________________________________
(Enthusiast)
(Friend)
(Student)
Please return this form with your credit card information or check payable to: Montana Museum of Art &
Culture, The University of Montana, Main Hall, Room 006, Missoula, MT 59812 Thank You! You will receive a
Yes! I/We want to be a member of MMAC!
Enclosed
2014-15
Enclosedisismy
my
2014
membership gift
membership
gift of:
of:
Name(s): ________________________________________________________
 $1,000
$1,000and
andabove
above
Address: ________________________________________________________
City: __________________________ State: _________ Zip: _____________
(Champion)

Phone Number: ___________________________________________________
$500
$500 --$999
$999
(Visionary)
Email: __________________________________________________________

$250
$250 --$499
$499
PAYMENT INFORMATION

$100
$100 --$249
$249

$50
$50 --$99
$99

$25
$25 --$49
$49

Check Enclosed

American Express
(Patron)
(Advocate)

Visa

MasterCard

Discover
Card Number: ____________________________________________________
Expiration Date: _____________________ Auth. Number: ________________
Signature: _______________________________________________________
(Enthusiast)
(Friend)

$0,
$0, free!
free!
(Student)
Please return this form with your credit card information or check payable to: Montana Museum of Art &
Culture, The University of Montana, Main Hall, Room 006, Missoula, MT 59812 Thank You! You will receive a
Yes! I/We want to be a member of MMAC!
Enclosedisismy
my
2014
Enclosed
2014-15
membership
gift of:
of:
membership gift
Name(s): ________________________________________________________
$1,000and
andabove
above
 $1,000
Address: ________________________________________________________
(Champion)
City: __________________________ State: _________ Zip: _____________
$500 --$999
$999
 $500
Phone Number: ___________________________________________________
(Visionary)
Email: __________________________________________________________
$250 --$499
$499
 $250
PAYMENT INFORMATION
 $100
$100 --$249
$249

Check Enclosed

American Express
(Patron)
(Advocate)

Visa

MasterCard

Discover
Card Number: ____________________________________________________
Expiration Date: _____________________ Auth. Number: ________________
Signature: _______________________________________________________
$50 --$99
$99
 $50
(Enthusiast)
$25 --$49
$49
 $25
(Friend)
$0, free!
free!
 $0,
(Student)
Please return this form with your credit card information or check payable to: Montana Museum of Art &
Culture, The University of Montana, Main Hall, Room 006, Missoula, MT 59812 Thank You! You will receive a