Sponsorship Registration Please enable JavaScript in your browser to complete this form.COMPANY NAME *CONTACT PERSON *FirstLastMAILING ADDRESS *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEMAIL *PHONE *PLEASE SELECT A SPONSORSHIP LEVEL *Mary Alice Membership Circle - $1,000.001976 Membership Circle - $750.001784 Membership Circle - $500.00WACO Historical Preservation CircleBenefactor Circle - $100.00Living History Sponsor - Other AmountWOULD YOU LIKE TO USE A COMPANY LOGO IN SPONSORSHIP PUBLICATIONS *YESNOI WOULD LIKE THE SPONSORSHIP TO BE PRIVATEWOULD YOU LIKE TO UPLOAD YOUR COMPANY LOGO WITH THIS REGISTRATION? *YESNOCLICK ON THE BOX BELOW TO ADD YOUR LOGO (PDF, JPG, PNG) Click or drag a file to this area to upload. PAYMENT OPTIONS FOR SPONSORSHIP *I will submit payment by checkI would like to pay with a credit cardI would like to pay with an ACH bank draftSPONSORSHIP PAYMENT WITH A CHECK SPONSORSHIP PAYMENT WITH A CARD The Washington County Historical Society accepts credit cards through our account with PayPal. An email invoice will be sent to the email you have provided. The email will contain a secure link for paying with a credit card. You don't have to have a PayPal account to use this service. VISA, Mastercard, American Express & Discover cards are acceptable. Thank you for your support!SPONSORSHIP PAYMENT WITH AN ACH DEBIT With you authorization, the Washington County Historical Society can draft your payment from you finanical institutions checking account. Your information is secure and orginated by Citizens Bank of the South. Please provide the following information. YOUR USE CHECKING NAME ASSOCIATED WITH CHECKING ACCOUNT *NAME OF THE DEPOSITORY FINANCIAL INSTITUTION *ABA ROUTING NUMBER *ACCOUNT NUMBER *AMOUNT OF SPONSORSHIP TO BE DRAFTED *ONE-TIME ACH DEBIT AUTHORIZATION FORM I certify that I am an authorized signor on the Depository Account and I givepermission for a single transaction only. As an authorized signor on the Depository Account presented, by completing and signing this form I give the Washington County Historical Society, Inc. permission to debit your account, one-time, for the amount indicated on or after the next business date after submission.SIGN OR TYPE YOUR NAME BELOW *Submit
