Business Member Levels

HISTORIC MACON FOUNDATION, INC PRESERVATION PARTNER PLEDGE FORM

Company Name:

_____________________________________________________

Contact and Title:

_____________________________________________________

Company Address: _____________________________________________________ _____________________________________________________ City State Zip Phone:_______________________________Fax: _____________________________ E­Mail Address__________________________________________________________

Preservation Partner Levels (See attached sheet for incentives for various levels of sponsorship)

$5,000 ($420/month)*

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$2,500 ($210/month)*

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$1,000 ($85/month)*

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$600 ($50/month)*

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$300 ($25/month)*

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Method of Payment _______ Check enclosed (Please use this application as an invoice) Credit Card ______ Visa _____ MasterCard Credit Card # ____________________________________ Expiration Date ___________ *Monthly Contribution: I would like make my contribution by credit card in monthly installments. I hereby authorize Historic Macon Foundation to charge my credit card monthly until further notice. _________________________________ Signature Make Payment to: Historic Macon Foundation, Inc., P.O. Box 13358, Macon, GA 31208 Request by___________________________ Approved by___________________________ Historic Macon Representative Company Representative Invoice date ___________