Mod/Co Application

* Indicates a required field

Please provide information for how your institution will be listed and printed in the brochures

Name of institution*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Website*

Mission statement or description of your institution's focus*

Hours of operation*

Please list any days/holidays your institution is closed to the public*

Please list the benefits that will be given to visiting Mod/Co members (in addition to free admission)*

Discount at the store Discount at the cafe Discount for performances

Other:

Please provide an estimated number of members of your institution who give at the $150-level and above*

Please provide contact information for the managing individual at your institution. The following information is simply intended to identify the appropriate contact person at each institution and will not be published in the brochure.

Name*

First Name

Last Name

Title*

Mailing address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Fax

Email*

Authorized signature*

[clear]

Use your mouse or finger to draw your signature above

Date*

Feel free to suggest any other institutions that you think should be in the program