I have reviewed the Associate Member levels and

would like to enroll at the following level:

_____Basic ($20) _____Donor ($100)
_____Contributor ($50) _____Benefactor ($150)
_____Sponsor ($75) _____Patron ($250)

_______Golden Circle ($500)

_____ I have enclosed my check made payable to Mario Lanza Institute
_____ I want my contribution to go further so I am declining all benefits and goods
_____ My company will match my gift in the amount of $_________
_____ I have enclosed my company's matching gift application

Name: …………………………………………….

Address: ……………………………………………..

City: ………………………. State: ……….. Zip Code: ………………………

Country: …………………………….

Telephone No.: ……………………….. E-Mail: ………………………………

Please print out this page and include it with your check. Mail to:

Mario Lanza Institute
P.O. Box 54624
Philadelphia, PA 19148-0624

Payments from outside the USA should be by check or money order
in US funds drawn on an American bank