Ocmulgee National Monument Association
 
New ____	Renewal ____

NAME: ___________________________________________________________
ADDRESS: _______________________________________________________________ 
EMAIL: __________________________________________________________________
PHONE NUMBER :(home) __________________ (work) ________________________
MEMBERSHIP LEVELS 
___ $15 Student/Senior	___ $100 Contributing	___ $500 Corporate 	
___ $25 Individual 	___ $200 Patron		
___ $50 Family 	___ $250 Sustaining	___ $1000 “All Things are Connected” Club.	

•	All levels include invitations to events and 20% discount in the Museum Store
•	Individual, Family and Contributing include newsletter listing, tickets to Indian Celebration and Lantern Tours
•	Patron, Sustaining, Corporate, and “All things are Connected” Club include above and tickets to Indian Celebration Performer’s dinner and Annual Patron’s Recognition Reception

METHOD OF PAYMENT 		____ Check Enclosed 
Credit Card:    __Visa     __ MasterCard 		Signature: _________________________________
Credit Card # __ __ __ __   __ __ __ __   __ __ __ __   __ __ __ __   Exp____/_____ 
Mail form to:	Ocmulgee National Monument Association
		Ocmulgee National Monument
		1207 Emery Highway
		Macon, Georgia 31217-4320