Fillable University of Southern Mississippi - Partners for the Arts Membership Form

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University of Southern Mississippi - Partners for the Arts Membership Form

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Country of origin: US
File type: PDF

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I WANT TO BECOME A
PARTNER FOR THE ARTS
NEW MEMBER RENEWAL
Name __________________________________________________
(as you wish it to be listed)
Address _________________________________________________
City/State/ZIP ___________________________________________
Phone __________________________________________________
Email __________________________________________________
Sign me up to receive email updates
In honor of
or
in memory of ________________________________________
(name as you wish it to be listed)
PLEASE CHECK A LEVEL OF GIVING
INDIVIDUAL/ CORPORATE (Annual Membership)
President’s Circle ($5,000+)
Grand Benefactor ($2,500)
Benefactor ($1,000)
Patron ($500)
Donor ($250)
Contributor ($150)
Friend ($50)
WOULD YOU LIKE TO DESIGNATE YOUR GIFT?
METHOD OF PAYMENT
CASH CHECK
Become a partner or renew online, visit: usm.edu/partners-arts
CREDIT CARD
VISA MASTERCARD AMEX DISCOVER
PRINT NAME ON CARD __________________________________
ACCOUNT NO. _________________________________________
EXP. DATE__________ CVV________ AMOUNT $ _____________
PAYROLL DEDUCTION (Southern Miss employees only)
Employee ID Number _________________________________
9-MONTH (FACULTY) 12-MONTH (FACULTY/STAFF)
BI-WEEKLY (HOURLY) SALARIED (MONTHLY)
MATCHING GIFT (enclose form)
MATCHING GIFT COMPANY _______________________________
SIGNATURE ____________________________________________
F O R FUR THER I NFO RMATION,
C A LL 60 1.266.5922
MAIL THIS FORM WITH PAYMENT TO
Partners for the Arts
The University of Southern Mississippi
118 College Drive #5004
Hattiesburg, MS 39406-0001
Seventy-five percent of your total contribution may be designated to an area of choic
e.
The remainder of those funds, including undesignated funds, will be applied dir
ectly to
the Partners for the Arts grants program.
The USM Foundation is a 501(c)(3) nonprofit organization. Contributions are tax-
deductible to the extent of current IRS regulations.
Gold
Silver
Bronze
ANNUALLY
$500o
$2,500
$1,000
LEGACY SOCIETY
*over five years
$25,00
0
$12,500
$5,000
MONTHLY
$416
$208
$83
LEGACY
(Gifts for Legacy Endowment)
Art and Design
Creative Writing
Dance
Music
Theatre
Friend of the Arts (all disciplines)
*Please note that seventy-five percent of your LEGACY gift
will support the PFTA Endowment
Media and Entertainment Arts
✔
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University of Southern Mississippi - Partners for the Arts Membership Form

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Completed 21 April 2020

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