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                <span class="header first">Planned Giving</span>
                        <a href="/thevlm/giving/1.html" class="vgnav_1 ">Welcome</a>
                        <a href="/thevlm/giving/2.html" class="vgnav_2 ">Our Legacy Society</a>
                        <a href="/thevlm/giving/3.html" class="vgnav_3 ">Meet Our Donors</a>
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                <span class="header">Ways of Giving</span>
                        <a href="/thevlm/articles/5.html" class="vgnav_12 ">Goals & Benefits</a>
                        <a href="/thevlm/articles/1.html" class="vgnav_8  ">
            Gifts Anyone Can Make        </a>
                                <a href="/thevlm/articles/2.html" class="vgnav_9  ">
            Gifts That Pay You Income        </a>
                                <a href="/thevlm/articles/3.html" class="vgnav_10  ">Gifts That Protect Your Assets</a>
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                <span class="header">More Information</span>
                        <a href="/thevlm/giving/8.html" class="vgnav_14 ">For Professional Advisors</a>
                        <a href="/thevlm/giving/4.html" class="vgnav_4 ">Contact Us</a>
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            <h1 class="vgpage_title pg-page-title">Our Legacy Society — Member Profile</h1>
        

    
        <p>Please fill out the form below to send us your Member Profile, so that we may welcome you into Our Legacy Society.</p>

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<div id="vg_member_profile">
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        <fieldset id="contact_info">
            <legend><strong>Please note:</strong> All highlighted and starred (*) fields are required.</legend>

            <div class="pg-input-wrap pg-input-text">
                <label for="form_name">Name(s): * </label>
                <input name="form_name" type="text" id="form_name" value="" size="30" maxlength="50" />
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            <div class="pg-input-wrap pg-input-text">
                <label for="form_age1">Age:</label>
                <input name="form_age1" type="text" id="form_age1" value="" size="30" maxlength="50" />
            </div>
            <div class="pg-input-wrap pg-input-text">
                <label for="form_age2">Age (Spouse):</label>
                <input name="form_age2" type="text" id="form_age2" value="" size="30" maxlength="50" />
            </div>
            <div class="pg-input-wrap pg-input-text">
                <label for="form_address">Address: * </label>
                <input name="form_address" type="text" id="form_address" value="" size="30" maxlength="50" />
            </div>
            <div class="pg-input-wrap pg-input-text">
                <label for="form_citystatezip">City/State/Zip: * </label>
                <input name="form_citystatezip" type="text" id="form_citystatezip" value="" size="30" maxlength="100" />
            </div>
            <div class="pg-input-wrap pg-input-text">
                <label for="form_country">Country: </label>
                <input name="form_country" type="text" id="form_country" value="" size="30" maxlength="100" />
            </div>
            <div class="pg-input-wrap pg-input-text">
                <label for="form_phone">Telephone: *</label>
                <input name="form_phone" type="text" id="form_phone" value="" size="30" maxlength="50" />
            </div>
            <div class="pg-input-wrap pg-input-text">
                <label for="form_email">E-Mail: *</label>
                <input name="form_email" type="text" id="form_email" value="" size="30" maxlength="100" />
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        </fieldset>

        <fieldset id="anonymous">
            <legend><strong>Choose Below:</strong></legend>

            <div class="pg-input-wrap pg-input-radio">
                <input name="form_nameanon" id="form_nameanon1" type="radio" value="1" />
                <label for="form_nameanon1">The Virginia Living Museum may include my (and, if applicable, my spouse's) name in Our Legacy Society listings.
                    (Neither amount nor designation, if provided, will be included on the listing.)</label>
            </div>
            <div class="pg-input-wrap pg-input-radio">
                <input name="form_nameanon" id="form_nameanon2" type="radio" value="0" />
                <label for="form_nameanon2">I am honored to be included in Our Legacy Society; however, I prefer to remain anonymous. Please do not include my/our name in Our Legacy Society listings.</label>
            </div>
        </fieldset>

        <h2>Please share with us, in confidence, more about your estate provision for the Virginia Living Museum. The following information is optional.</h2>

        <fieldset id="beneficiary">
            <legend><strong>I have named the Virginia Living Museum as a beneficiary of my:</strong></legend>



            
            <h3>Gifts Anyone Can Make</h3>

                        <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_bequest"><input name="form_bequest" type="checkbox" id="form_bequest" value="checked"  /><span>Will or Trusts</span></label>
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                                    <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_appsec"><input name="form_appsec" type="checkbox" id="form_appsec" value="checked"  /><span>Appreciated Securities</span></label>
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                                    <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_lifeins"><input name="form_lifeins" type="checkbox" id="form_lifeins" value="checked"  /><span>Life Insurance</span></label>
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                                    <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_ira"><input name="form_ira" type="checkbox" id="form_ira" value="checked"  /><span>Retirement Plans</span></label>
            </div>
                                                                        


                        <h3>Gifts That Pay You Income</h3>

                        <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_cga"><input name="form_cga" type="checkbox" id="form_cga" value="checked"  /><span>Charitable Gift Annuity</span></label>
            </div>
                                    <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_dga"><input name="form_dga" type="checkbox" id="form_dga" value="checked"  /><span>Deferred Gift Annuity</span></label>
            </div>
                                                            <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_pif"><input name="form_pif" type="checkbox" id="form_pif" value="checked"  /><span>Pooled Income Fund</span></label>
            </div>
                                    <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_crut"><input name="form_crut" type="checkbox" id="form_crut" value="checked"  /><span>Charitable Remainder Unitrusts</span></label>
            </div>
                                    <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_crat"><input name="form_crat" type="checkbox" id="form_crat" value="checked"  /><span>Charitable Remainder Annuity Trusts</span></label>
            </div>
                        

            
            <h3>Gifts That Protect Your Assets</h3>

                        <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_bargain"><input name="form_bargain" type="checkbox" id="form_bargain" value="checked"  /><span>Bargain Sale</span></label>
            </div>
                                    <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_clt"><input name="form_clt" type="checkbox" id="form_clt" value="checked"  /><span>Charitable Lead Trust</span></label>
            </div>
                                    <div class="pg-input-wrap pg-input-checkbox">
                <label for="form_rle"><input name="form_rle" type="checkbox" id="form_rle" value="checked"  /><span>Retained Life Estate</span></label>
            </div>
                        

            

        </fieldset>

        <fieldset id="provision">
            <legend><strong>This provision is stated as a:</strong></legend>



            <input name="form_sdacheck" type="checkbox" id="form_sdacheck" value="checked" />
            <label for="form_sdacheck">Specific dollar amount ($):</label>
            <input name="form_sda" onChange="javascript:document.societyform.form_sdacheck.checked = true" type="text" id="form_sda" value="" title="Specific Dollar Amount Value" />



            <br clear="all" />
            <input name="form_peacheck" type="checkbox" id="form_peacheck" value="checked" />
            <label for="form_peacheck">Percentage of estate/account (%):</label>
            <input name="form_pea" type="text" id="form_pea" value="" title="Percentage of Estate/Account Value" onChange="javascript:document.societyform.form_peacheck.checked = true" />

            <fieldset>
                <legend><strong>Based on Percentage:</strong></legend>
                <label for="form_ecv">If based on a percentage, please estimate the current value of the gift to the Virginia Living Museum ($):</label>
                <input name="form_ecv" type="text" id="form_ecv" value="" onChange="javascript:document.societyform.form_peacheck.checked = true" />
            </fieldset>
        </fieldset>

        <fieldset id="restriction">
            <legend><strong>My gift is:</strong></legend>

            <input name="form_unrestricted" type="checkbox" id="form_unrestricted" value="checked" />
            <label for="form_unrestricted">Unrestricted (General Operations)</label>
            <br clear="all" />
            <input name="form_designated" type="checkbox" id="form_designated" value="checked" />

            <label for="form_designated">Designated for:</label>
            <input name="form_designatedfor" onChange="javascript:document.societyform.form_designated.checked = true" type="text" id="form_designatedfor" value="" title="Gift Designation Details" />
        </fieldset>

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