New Orleans
Pharmacy Museum

HELP PRESERVE HISTORY

Join the New Orleans Pharmacy Museum

            INDIVIDUAL ($50)                                                FAMILY ($75)

            SUSTAINING ($100)                                             PHARMACY FRIEND ($250)

            INDIVIDUAL LIFETIME ($500)                           CORPORATE MUSEUM PARTNER ($500)

            CORPORATE FELLOW ($1000)

This membership is         New          Renewal

Membership information

Mr./Ms./Mrs./Dr.

                                                                                                                                                                                   
Name

                                                                                                                                                                                   
Address

                                                                                                                                                                                   
City                                                                   State                                Zip

                                                                                                                                                                                     
Phone                                                            Phone (business)                                E-mail address

        Check or money order payable to The New Orleans Pharmacy Museum        $                                             
                                                                                                                                                  amount enclosed
         Visa                 Mastercard                 American Express

                                                                                                                                                                                     
Account #                                                                                                         Expiration Date

                                                                                                                                                                                     
Signature

THANK YOU FOR YOUR GENEROSITY

Mail to:    New Orleans Pharmacy Museum
                514 Chartres Street
                New Orleans, LA 70130

Credit Card Payments:     may be made by faxing this form to (504) 565-8028
For more information please call (504) 565-8027.  All inquiries are confidential and without obligation.

514 Chartres Street
New Orleans, LA 70130
(504)565-8027
fax (504)565-8028
nopharmsm@aol.com