Friends Of The Blaine House
Become a Member

Click here for our new Secure Online Membership Form, or if you prefer to send in the form and contribution via the US Postal Service, please fill out and print the form below.

Please fill out the form below and include with your payment.
If paying by check, please make it payable to: Friends of the Blaine House,
Return to: PO Box 68, Augusta, ME 04332

___ Individual $25 ___ Patron $500
___ Family $50   ___ Business $1000
___ Supporter $100   ___ Special Friend $1000
___ Benefactor $250   ___ Other gift ______

Please direct my donation for use on the project(s) I select:
_____ Restoration
_____ New England Garden
_____ Greenhouse
_____ Game Room
Name: ____________________________________________________
Address: ____________________________________________________
City: _______________ State: _____ Zip: __________
Phone: _______________ Email: _______________________
Fax: _______________    
       

Additional Instructions:

 

 

 

Please charge my: ___ Mastercard ___Visa

___ AMEX

 

Card # ______________________________

 

 Exp. Date __________

Signature _______________________________