Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *DONOR BENEFITS $25,000-$10,000 • Name placement on Wall of Fame • Special invitation to Grand Opening • Special invitation to progress luncheon • Two tickets to Black Box production of your choice $9,999 - $5,000 • Name placement on Wall of Fame • Special invitation to Grand Opening • Special invitation to progress luncheon $4,999 - $1,000 • Name placement on Wall of Fame • Special invitation to Grand Opening $999 - $100 • Name placement on Wall of Fame Donation Amount *Comment or Message *Please indicate here how you would like your name entered in the Theatre Salina Playbill, or any special instructions about your donation. Authorize.Net *Card NumberMM123456789101112Expiration/YY2425262728293031323334Security CodeCredit Card payments are processed securely through Authorize.netSubmit
