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| Pledge Information |
| Name:____________________________________________: |
| Address:______________________________: |
| City:_______________ State: ____Zip:_________: |
| Telephone (home)(___)_____-_____________: |
| Telephone (business)(___)_____-_____________: |
| Fax(___)_____-_____________: |
| E-Mail:_______________________@_________________________________: |
| I (we) pledge a total of $to be paid: now monthly quarterly yearly. |
| I (we) plan to make this contribution in the form of: cash check |
| Gift will be matched by __________________________________(company/family/foundation). |
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Please make checks, corporate matches, or other gifts payable to:
312 Cumberland, Ave. |
| Acknowledgement Information |
| Please use the following name(s) in all acknowledgements: |
| Name(s)______________________________________________________: |
| I (we) wish to have our gift remain anonymous. |
| Signature(s)______________________________:Date____/____/_______: |
