_____ $40 individual/family/senior/student
 

_____ $200 MSM Small Business                           

_____ $500 MSM Partner

_____ $1000 MSM Champion

_____ Additional contribution (100% tax deductible)

 

Name:______________________________________________________

Address:____________________________________________________

City, State, Zip:_______________________________________________
 

Business Name (if applicable)___________________________________

Email:______________________________________________________

Phone:_____________________________________________________ 

____ cash   

____ Check (payable to Main Street Medina)

 

Please completely fill out the form and send with payment to:

Main Street Medina