MEMBERSHIP APPLICATION FORM MEMBER INFORMATION Name:______________________________________________ Address:____________________________________________ City:_____________________ State:____ Zip:_________ - _______ Please select membership type: ______ $50 Individual ______ $40 Out of Town ______ $25 Student/Senior ______ $150 Associate ______ $500 Corporate Method of Payment: ______ Check ______ Visa ______ MasterCard Card Number:_____________________________ Expiration Date:_____ / _____ Signature:__________________________ Please print out and mail to: National Vietnam Veterans Art Museum 1801 S. Indiana Avenue Chicago, IL 60616 Or Fax to: 312-326-9767 For further information please contact the Museum at 312-326-0270 Thank you for your support.