CSC Benefactors Society

Name(s)*

First Name(s)Last Name

Email

example@example.com

Phone Number

Area CodePhone Number

Company (optional)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your name(s) as you want them to appear in Benefactors Society listings and on the Donor Wall:*

I/We wish to remain anonymousList me/us as:

List me/us as:

Membership Levels

$30,000 Corporate$24,000 Benefactor$12,000 Patron

Contribution Payment Plan

I/We would like to make one payment in full.I/We would like to pay in installments.

I would like to pay in full via:

Check (Payable to Cancer Support Community Greater SGV)Credit CardAppreciated Securities. Please contact me/us with stock transfer information.

I/We would like to pay in 1 - 10 Installments. (choose 1-10)

Installments will be paid by

CheckCredit CardAppreciated Securities

Benefactors Society Payment

USDDescription

$      by March 31, 2025
$      by June 30, 2025
$      by September 30, 2025
$      by December 31, 2025

Additional Notes

Signature to confirm membership

Signature 2 to confirm membership (for joint gift)

CSC Benefactors Society Membership Form