Aga Khan Museum Membership Contact Information Membership payment is being made by a company Organization Name Street Address Postal Code City State- State -ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYASGUMPPRVIFMMHPWAAAEAP Organization Email Organization Phone (Optional) First Name Last Name Street Address Postal Code City State- State -ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYASGUMPPRVIFMMHPWAAAEAP Email Home Phone (Optional) Mobile Phone (Optional) (Optional) Membership Levels Ticket Level Quantity Young Patron: Single ($385) Number of Young Patron: Single tickets ($385 each) - Quantity -1 Young Patron: Dual ($615) Number of Young Patron: Dual tickets ($615 each) - Quantity -1 Patron ($770) Number of Patron tickets ($770 each) - Quantity -1 Benefactor ($1,925) Number of Benefactor tickets ($1,925 each) - Quantity -1 Museum Circle ($3,850) Number of Museum Circle tickets ($3,850 each) - Quantity -1 Curator's Circle ($7,700) Number of Curator's Circle tickets ($7,700 each) - Quantity -1 Director's Circle ($19,250) Number of Director's Circle tickets ($19,250 each) - Quantity -12345 TOTAL: $0 QTY: 0 Payment Information Pay with Card Pay with Bank Account Card Number Expiration Date We cannot accept corporate ACH payments. Please provide a personal bank account or use a different payment method. Account Type Checking Savings Routing Number What's This? Account Number What's This? Confirm Account Number I authorize the use of my bank account as a payment method and authorize this organization to debit my bank account via the Automated Clearing House system to fulfill my donation commitment. This authority will remain in effect until revoked in writing by the account holder. Additional Information Friend/Patron #: (Optional) Second Cardholder (If Applicable) (Optional) Auto-renewal: I wish to continue my support on an annual basis. I understand that I may change or cancel this authorization at any time. (Optional) Auto-renewal: I wish to continue my support on an annual basis. I understand that I may change or cancel this authorization at any time. is required. Yes Your donation will be securely processed.