The Franklin Institute Individual Contribution Form

Please print this form, then fill it out and mail it with check or credit card number.

Name ___________________________________________

Address _________________________________________

City _____________________ State ___________

Postal Code ____________

Phone _________________________

If you would like to receive our electronic newsletter, please provide your email address. _____________________________________________

Enclosed is my:
O Check
O Credit card (circle one) VISA | MC | AMEX | Discover

Acct # _____________________________ Exp. Date __________

Signature ________________________________________

Donor Club Levels
O $175 - Millennium Fund (100% tax-deductible)
O $300 - Friends' Circle ($175 tax-deductible)
O $500 - Patrons' Circle ($375 tax-deductible)
O $1,000 - Ben's Booster ($825 tax-deductible)

O I opt to waive all benefits so my gift is deductible to the full extent of the law.

O I do not wish to join a donor club at this time, but I would like to make a tax-deductible gift of $_____________ to the Annual Fund.

For gifts of $175 or more, please note how you would like your name to appear in our Annual Report.
__________________________________________________

Please mail to:
Development Department
Attention: Manager of Individual Giving
The Franklin Institute
222 N. 20th Street
Philadelphia, PA 19103

Questions? Please call our Manager of Individual Giving, at (215) 448-1157. Thank you for your support!