Please fill out the following, then select your payment option.

Print your name__________________________________________________________

Signature_______________________________________________________________

Address________________________________________________________________

City__________________________________ State________ ZIP_________________

Phone: Home_______________ Work ________________ E-mail__________________

Name(s) appearing in the program ___________________________________________

I want to make a donation of stocks and/or securities; please phone me with details.

I am eligible for a matching gift from ______________________________
(Please enclose the matching gift form provided by your company/employer)

I have included the NMSO in my will.

Payment option:

• Check $____________ (amount)
• Charge to my credit card: ___ MasterCard   ___ Visa   ___ American Express    ___ Discover
  • One payment of $__________ (amount), OR
  • Monthly payments of $__________ (amount)

    Credit card number ___________________________________________________
    
    Expiration date ____/____
    
    Signature____________________________________________________________

• Please bill me $__________ (amount)
• I prefer to pay by direct debit withdrawal from my bank account.
  Debit my bank account in monthly installments of $_________ (amount)
  Select one: Checking account ___   Savings account ___
  (A voided check or savings deposit slip showing your account number must be attached to this form.)
  
  Bank/Credit Union name _________________________________________________
  
  I hereby authorize the New Mexico Symphony Orchestra (NMSO) to initiate debit entries and if necessary credit the same to the above-named financial institution and account.
  
  This authorization is to remain in full force and effect until the NMSO has received written notification from me to its termination in such time and in such manner to afford the NMSO and the depository a reasonable opportunity to act on it.
  
  Signature______________________________________________________