Membership Categories:
□ Platinum Member $1,000 & up
□ Gold Member $999 - $500
□ Silver Member $499 - $250
□ Bronze Member $249 - $100
□ Other __________
Amount Pledged $ __________ Amount Paid $
____________
I agree to pay this amount for: □ 1 Yr. □
2 Yr. □ 3 Yr. □ 4 Yr. □ 5 Yr.
Please bill me: □ Monthly □ Quarterly □
Semi-Annually □ annually, beginning on _________ (date).
□ My check, payable to
the Haliwa-Saponi Tribal Building Fund, is enclosed.
□ Please charge my gift to: □ VISA □
MasterCard - Card Number: _______________________
Exp. Date___________
Signature:_____________________________________________
Date: ______________________
□ Please draft my checking account monthly in
the above agreed amount (please enclose voided check), beginning on
__________________(date).
Signature:______________________________________________
Date:______________________