_____ Individual - $30 _____ Family - $50

_____ Silver - $100 _____ Gold - $250 _____ Platinum - $500

Does your employer have a matching gifts program? _____Yes _____No

Name:_______________________________________________

Address:_____________________________________________

City:__________________ State:___________ Zip:__________

Phone:____________________ Email:_____________________

Please print out this form and send it with your payment to:

The Needham Historical Society
1147 Central Avenue
Needham, MA 02492