I would like to make a donation to the Mount Airy Museum of Regional history as noted below:

Please check one: Memorial Gift ___________

My Name: __________________________________

My Address: ________________________________

__________________________________________

 

Tribute Gift __________

Amount $______________
Honored Person: ________________________________

Address: ______________________________________

_____________________________________________

Person or Persons to be notified: ___________________________________________________________________

Address ______________________________________________________________________________________

Please print and mail this to: Mount Airy Museum of Regional History • 301 North Main Street • Mount Airy, NC 27030