Title ________
Name ________________________________________________________________________
Address ______________________________________________________________________
City ________________________________________________________ State __________
Zip Code _______________________ Country __________________
Phone # ____________________________________________________
E-Mail _____________________________________________________
Gift Amount $_______________ ($10 minimum for online contributions) Credit Card (VISA or MasterCard) _______________________________ Name as it appears on Card _______________________________________________________ Card # ______________________________________________________ Expiration Date (MM/YY) _______________________________________ |
My company has a gift matching program (Yes/No) ___________ If
yes, please provide following information:
Company Name ________________________________________________________________
Address ______________________________________________________________________
City ________________________________________________________ State __________
Zip Code _______________________ Country __________________
Note: The following fields are required only if you are
making a
contribution in honor or memory of someone.
My contribution is (circle one): IN HONOR OF / IN MEMORY OF Name ________________________________________________________________________ Occasion ______________________________________________________________________ If your contribution is in honor/memory of someone, to who should an acknowledgement be sent: Title ________ Name ________________________________________________________________________ Address ______________________________________________________________________ City ________________________________________________________ State __________ Zip Code _______________________ Country __________________ How would you like the acknowledgement to be signed? ______________________________________________________________________________ |
____ Please contact me about planned giving opportunities
Additional comments ____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________