Mail This Form To: MELA Foundation / 275 Church Street, #2 / New York, NY 10013

MEMBERSHIP - YES! I WANT TO SUPPORT MELA'S PROJECTS AND BECOME A MEMBER AT THE FOLLOWING LEVEL...

$30 Artist/Student	$50 Friend	$100 Associate
$250 Fellow
$500 Sponsor
$1,000 Donor
$2,500 Patron
$5,000 Benefactor
$10,000 Guarantor

Enclosed is my contribution of: $

Does your employer have a matching contributions program? Circle Yes or No.
If YES, please attach a company business card to your order. YES
NO

NOTE: Your contribution will be tax-deductible to the extent allowed by law, minus the retail value of your benefit gift. Do you prefer that we withhold the membership benefit and apply your entire contribution to supporting the work of MELA Foundation? Please circle Yes or No. YES
NO

CATALOG ITEMS - PLEASE LIST EACH ITEM AND INDICATE PRICE EACH, QUANTITY AND TOTAL...

Item Description	Price Each	Quantity	Total






SUBTOTAL OF CATALOG ITEMS:	XXXX	XXXX	$
8.50% SALES TAX (NYS RESIDENTS ONLY)	XXXX	XXXX	$
ADD SHIPPING	XXXX	XXXX	$
ADD MEMBERSHIP	XXXX	XXXX	$
ORDER TOTAL	XXXX	XXXX	$

Name:		Phone:
Address Line 1:		City:
Address Line 2:		State/Zip:
Email:		Country:

Enclosed is my contribution of:	$
Does your employer have a matching contributions program? Circle Yes or No. If YES, please attach a company business card to your order.	YES NO
NOTE: Your contribution will be tax-deductible to the extent allowed by law, minus the retail value of your benefit gift. Do you prefer that we withhold the membership benefit and apply your entire contribution to supporting the work of MELA Foundation? Please circle Yes or No.	YES NO