PNB Contribution Form

(Print and Mail) *Required Fields

First Name*___________________________Last Name*__________________________

Name as you wish it to appear in the program:*__________________________________

___Please do not list my name in the program.

Address*_________________________________________________________________

City*____________________________________State/Province*____________________

Zip/Postal Code*__________________________Country___________________________

Home Phone*_(______)________________Business Phone_(______)________________

Email Address_____________________________________________________________

If you spoke with one of our telephone callers, please enter the caller's

identification number:________________________

I wish to contribute to PNB's Annual Fund as (check one):

  ___Stowell Society Ballet Masters Circle $10,000 and above
  ___Members of the Barre Scholarship Patron $5,000–$9,999
  ___Members of the Barre $3,000–$4,999
  ___Conductor's Circle $2,000–$2,999
  ___Dancers' Council $1,500–$1,999
  ___Choreographer's Club $750–$1499
  ___Principal $500–$749
  ___Soloist $250–$499
  ___Corps de Ballet $100–$249
  ___Donor $1–$99

I wish to support PNB's Annual Fund with a gift of $_____________

I wish to contribute to PNB's New Works Initiative (check one):
(See New Works Initiative Individual Donor Benefits)

  ___Sponsor $10,000+
  ___Visionary $1,000–$9,999
  ___Donor $1–$999

I wish to support PNB's New Works Initiative with a gift of $_____________

Payment Options:

Please choose one of the following payment options:

___I would like to charge my contribution to my credit card.
     (Please fill in credit card information below)

___I wish to charge $__________ now; for the remainder, please:
     ___Bill me
     ___Charge my credit card:

         ___Semi-Annually
         ___Quarterly
         ___Monthly

    CREDIT CARD Information:
    Card Type (circle one) VISA          MasterCard         AMEX         Discover

    Card Number___________________________________

    Expiration Date______________

    Signature_________________________________Date_____________

___I am enclosing a check payable to Pacific Northwest Ballet.

___My company has a Matching Gift program.
     ___I am enclosing the completed form.
     ___I am mailing the completed form separately.

PLEASE MAIL COMPLETED FORM TO:
   Pacific Northwest Ballet
   Attn: Director of Development
   301 Mercer St.
   Seattle, WA 98109

For further information regarding how you can support Pacific Northwest Ballet, please contact the Membership Office at 206-441-3593 or giving@pnb.org