Martin House Associates Membership Application

Yes, I want to be a member of the Martin House Associates. 

[ ] Wright Circle: $10,000 or more              [ ] Special Patron: $5,000
[ ] Patron: $2,500				[ ] Sustaining: $1,000
[ ] Charter: $500				[ ] Sponsor: $250
[ ] Contributor: $100			        [ ] Family: $60
[ ] Individual: $35				[ ] Student: $25
[ ] Other: $___________

Please select one: [ ] Mr.     [ ] Mrs.     [ ] Miss.     [ ] Ms.

First name:	_________________________________

Last name:	_________________________________

Address:	_________________________________

City:		_________________________________

State:		_____ (Please use two digit abbreviation)

Country:        ____________________

Zip code:	____________

Telephone number:________________

Email address:	_________________________________

This is a gift membership in the name of:  _________________________________

Please list my/our name as follows in the donor listing:  _________________________________


Please indicate your MASTER CARD or VISA information below:

Credit card number: _________________________________

Expiration date:    ____________________

Name on card:       _________________________________


Please send your check, money order, Visa/Master Card along with this application to:

Martin House Restoration Corporation
Market Arcade
617 Main Street
Buffalo, New York 14203

Fax: 716-856-4009

Questions can be directed to Dawn Warsaw, Assistant Director, Capital Campaign - 716-856-3858


Thank You for Your Membership.