Giving Opportunity Form

Full Name

Address

City, State & Zip

Phone Number

Day:

Evenings:

I pledge to give my tax-deductible annual contribution of:

$5000 ($417 a month)

$1500 ($125 a month)

$250 ($21 a month)

$2500 ($208 a month)

$1000 ($83 a month)

$100 ($8 a month)

$2000 ($167 a month)

$500 ($42 a month)

Other _________________

Wish to remain anonymous
You may publish my contribution

My pledge is for a period of

Two Years

Three Years

Four Years

Five Years

Other ____________

I select the folllowing method of payment:

Cash

Check

Please complete the information below for credit card/debit one time only or monthly donations:

Credit Card
Visa	Mastercard	American Express	Discover