| Telephone : _______________________ |
Cell: _______________________ |
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| E-Mail: _______________________________________________________ |
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| Donation Amount: $ ____________________________________________ |
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| Please Use My Gift For: |
General Operations __ Financial/Scholarship Assistance __
Outreach __ |
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| In Memory of: _________________________________________________ |
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| In Honor Of: _______________________ |
Other: _____________________ |
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| Please, if you wish a note of your generosity, name of persons and address necessary: |
| _____________________________________________________________ |
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| _____________________________________________________________ |
| ___ I wish this gift to be anonymous |
| ___ I wish to be notified in the future of special events |
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| Credit Card Information: _________________________________________ |
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| Card # ___________________________ |
Expiration Date: ______________ |
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| Type of Card: __Am Express __Discover __Master Card __Visa |