Pledge Form

[Organization Name] [Mission Statement]

Donor Information (please print or type)

Name
Billing address
City, ST Zip Code
Phone 1 | Phone 2
Fax | Email

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 | Exp. date
Credit card number
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
Please make checks, corporate matches, or other gifts payable to:	[Organization Name] [Street Address] [City, State ZIP Code]