Luxembourg American Cultural Society

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

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 :

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:


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

If you would like to make an additional Donation to the Luxembourg American Cultural Society, please enter amount here:
$ USD/Euro €

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

To download a printable version of the Membership application, Click Here!.