Membership

The Nebraska-Iowa Kiwanis District Foundation

Membership Application

	I a member of the District Foundation at the Level. (for Associate level membership, I pledge $25 contribution for the next three years.)
	I want to make a gift to honor
	I am interested in learning more about the Legacy Society. Please contact me.

Contributor:

      First Name:     Middle Initial:    Last Name:
Street Address:
                  City:      State:    ZIP Code:
       Address is:
Home Telephone:    Work Phone:
Email Address:
                  Club:     Division:

Contribution:

Amount of Contribution:
             Payment Method:
                   Card Number:    Expiration Month: Year:

Presentation Information:

For Life Members and Bartlett Fellows, I want a plaque. Name on plaque:
Check here if this is an anonymous gift. We will not release any information.
For Memorials and honoring another person, please provide the honored person's name:
Club:
For Memorials, please provide name and address for next of kin:

Please provide any comments or information needed for this application: