Pledge Form

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5/9 EXAMPLES

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Pledge Form
[Organization Name]
[Mission Statement]
Donor Information (please print or type)
Name
Billing Address
City
State
ZIP Code
Telephone (home)
Telephone (business)
Fax
E-mail
Pledge Information
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 ___ credit card ___ other.
Credit card type
Credit card number
Expiration Date
Authorized signature
Gift will be matched by _____________________ (company/family/foundation).
______ form enclosed _____ form will be forwarded
Acknowledgement Information
Please use the following name(s) in all acknowledgements.
____ I (we) wish to have our gift remain anonymous.
Signature(s):
Date: