MEMBERSHIP FORM for
GORE PLACE the Federal period historic house and estate in Waltham, MA
Please fillout, print and mail this form, along with check, money order (no cash please) or VISA/Mastercard information. Mail to:
Gore Place, 52 Gore Street, Waltham, MA 02453-6866
Please fill in your name and address:

First Name:    Last Name:

Address:

    City: State: Zip Code:

Email Address:

Phone Number (if paying by credit card):

Please BEGIN RENEW my Gore Place Society membership in the category checked below.

$25  Waltham/Watertown Resident
$30   Individual
$50   Dual/Family
$75 Friends of the Farm
$100 Sustaining
$250 Sponsor/Small Business 
$500 Supporting
$1,000 Patron/Corporate

 


Please indicate method of payment: Mastercard VISA Check

MC/VISA Number Expiration Date:

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