| Personal Information: |
___ This is my first gift to
the NHSO |
| |
___ I am renewing a gift to
the NHSO |
| Salutation |
_____ Mr. _____ Mrs. _____ Ms.
____Dr. _______________Other |
| First Name |
_____________________________________________ |
| Last Name |
_____________________________________________
|
| Address |
_____________________________________________ |
| City/State/Zip |
__________________________ State_____Zip
________ |
| Telephone |
Day ___________________
Evening _________________ |
| Email Address |
_____________________________________________ |
| |
Would you like to be included
in our Symphony Email List? |
| |
____ Yes ____ No |
| Donation Information: |
___ $ 100 Principal Player |
| |
___ $ 250 Concert Master |
| |
___ $ 500 Conductor's
Circle |
| |
___ $ 1,000 Composer's
Circle |
| |
___ $2,500 Virtuoso's
Circle |
| |
___ $5,000 Medici Circle |
| |
___ Other Amount $__________ |
| Payment Options: |
___ I am enclosing a personal
check (Mail Only) |
| |
___ Please charge my credit
card (Mail or Fax) |
| Credit Card Information: |
________________________________________
Name on Card |
| |
____ Mastercard ____ Visa ____
Discover ____ American Express |
| |
____________________________________ Card
Number |
| |
______________________________ Expiration
Date (00/00) |
| |
|
| Matching GIfts: |
_________________________________
Company Name |
| (Please fax or mail your matching
gift form.) |
___________________________Anticipated
Match Amount |
| |
|
| Donation Listing: |
___ Please list me in your Program
Book as indicated below: |
| (Donation of $50 or more) |
_____________________________________________ |
| |
___ I wish to remain anonymous. |
| |
|
| |
|
| |
|
114th SEASON
