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Membership Form

Yes! I will be a part of the Basie by becoming a member!

Chairman's Circle Gold $10,000+
Chairman's Circle Silver $5,000
Chairman's Circle Bronze $2,500
Chairman's Circle Benefactor $1,000
Chairman's Circle Supporter $500
Patron $275
Fellow $100
Sponsor $50

Name _____________________________________________________

Address ___________________________________________________

City ___________________ State ______ Zip ____________________

Phone _______________________ Email ________________________

Acknowledged as __________________________________

I have enclosed a check payable to Count Basie Theatre, Inc.

Please Charge $ _____________ to my American Express Discover Mastercard VISA

Credit Card Number __________________________________________________

Security Card Number __________________________________________________

Name on Card __________________________________________________

Expiration Date ______________________________________________________

Signature ___________________________________________________________

Automatically renew my membership next year by charging my credit card

I would like to volunteer.

Please send me information about bequests, planned giving and estate planning.

I have included information about my employer's matching gift program.

According to federal law applicable to charitable contributions, the IRS requires the Count Basie Theatre to inform you that 100% of your membership contribution to the Count Basie Theatre is tax deductible because no goods or services are exchanged in return for your contribution. The Count Basie Theatre respects the privacy of its customers and donors, and does not rent, sell, trade or exchange its mailing lists and databases.

Questions? Contact the Count Basie Theatre office at 732-224-8778.

Return this form with payment to: Count Basie Theatre Membership, 99 Monmouth Street, Red Bank, New Jersey 07701, fax 732-842-9323.

732-842-9000 countbasietheatre.org 99 Monmouth St. Red Bank, NJ 07701