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Luxembourg American Cultural Society, Inc.
P. O. Box 614
Port Washington, WI 53074
U.S.A.
Tele: (262) 376-3194
Fax: (262) 387-8694

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For Pioneer Individual
Membership or higher

 

Membership Application

Annual Individual and Family Membership

All fields marked with * are required.
*Choose Membership Type
Ambassador: $1000 / Euro 800€
Homesteader: $500 / Euro 400€
Settler: $250 / Euro 200€
Pioneer Family: $145 / Euro 115€
Pioneer Individual: $100 / Euro 80€
Immigrant Family: $60 / Euro 50€
Immigrant Individual: $35 / Euro 30€
Full-Time Student: $25 / Euro 15€
Complete for Full-Time Student Membership Only
*Student ID/ Certification #:  
*School:
*Membership Status: New   Renewal   Former Member   Gift  
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Member Information
*Member Name on Card (as you wish it to appear on Membership Card)
*Address:
Address 2:
*City: *State:
*Zip Code: County:
*Email: *Home Phone: ( ) -
Work Phone: Cell Phone :
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Complete for Gift Membership Only
This is a gift membership from:    
*Name:    
*Address: *City:
*State: *Zip Code:
*Home Phone: ( ) - Work Phone:
*Email: (confirmation of this transaction will be sent to)
Send Gift Announcement To: Recipient    Me
Send Renewal To: Recipient    Me
I would like gift announcement to read:
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PAYMENT INFORMATION: (As it appears on Credit Card)  
*Card Type: Same Name & Address as:
*Card Number: Member Information, Click Here!
*Exp. Date: / Gift Form Information, Click Here!
*Security Code:  What's This?  
*Name:    
*Address: *City:
*State: *Zip Code:
*Country    
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If you would like to make an additional Donation to the Luxembourg American Cultural Society, please enter amount here:
$ USD/Euro €
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Please send me additional information about: (check all that apply)
 Corporate Sponsorship  Planned Giving/Wills & Bequests
 Donations of Artifacts/Archives  Adult Education Programs
 Youth and Family Programs  Volunteer Opportunities
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To download a printable version of the Membership application, Click Here!.
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