Independence Circle
$500,000+ John Hancock Society
$250,000+ Benjamin Franklin Society
$100,000+ Samuel Adams Society
$50,000+ Robert Treat Paine Society
$25,000+ William Hooper Society

Head Masters' Circle
$10,000+ Epes Sargent Dixwell Society
$5,000+ Benjamin Apthorp Gould Society
$2,500+ Ezekiel Cheever Society
$1,000+ Philemon Pormort Society
$250+ John Cotton Society (for graduates of 15 years or less)

Purple Guard
Under $1,000

Name ________________________________________________ Class Year _________
Address _________________________________________________________________
City _____________________________ State ____________________ Zip ___________
Home Phone __________________________ Business Phone _____________________
E-mail Address ____________________________________________________________

I want to support quality education at BLS and support the mission of BLSA with a gift to the:
Unrestricted Fund
Other____________________________________________________

Gift Enclosed:   $1,000    $500    $100    Other _______________
Pledged gift: _________________ (to be fulfilled by June 30).

____________________________________________
Signature required for pledges

I prefer to charge my gift of $ _____________ to:
VISA    Mastercard    American Express

Account # _______________________________________ Expiration Date __________
Name as it appears on Card ________________________________________________

Signature _______________________________________________________________

Thank you for your tax-deductible gift.
Print form and mail to:
BLSA, 101 Huntington Avenue, Suite 200, Boston, MA 02199