Donation/Pledge Form Bridge to a Shared Perspective

Donation/Pledge Form

Capital Campaign for Perquimans Arts League
I wish to make a:
In the amount of $ total dollar amount of donation or pledge*
Pledges may be paid over three years.
Date established

MonthDayYear
today's date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Installment period, if making a pledge:
Installment amount, if applicable
Pledge Payment start date, if applicable

MonthDayYear
Method of payment
If stock is being donated, please list name of stock
Number of shares being donated, if applicable
Approximate value of stock, if applicable
Signature

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country