SLCC FOUNDATION Contribution Form

Give to SLCC

Name*

PrefixFirst NameLast Name

Company Name *

(If not applicable, please type "None")

Phone Number

Format: (000) 000-0000.

E-mail*

Highest Priority NeedCollege Innovation FundStudent Success and ScholarshipsOther

If you selected "Other," please indicate the gift purpose in the box below. If appropriate, please include the name of the individual(s) for which this gift is associated.

Credit CardDirect Deposit Authorization (ACH)

I would like to invest in SLCC at the following level.*

Donation$2,500.00

Donation$1,000.00

Donation$750.00

Donation$500.00

Donation$250.00

Donation$125.00

Donation$50.00

Donation$25.00

Other Amount for SLCC Donation$1.00

Amount ($)

Subtotal $0.00Tax $0.00Total $0.00

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

For recurring contributions, please select the date when you would like us to stop drafting your account. If this field is left blank, we will continue drafting your account until you notify us to discontinue the drafts.

Date

Name(s) on Bank Account (business name if used)*

Address Associated with Bank Account*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Routing Number*

must be 9 numbers - no spaces

Account Number*

Bank Name*

Bank Branch*

City, State

Bank Phone Number*

Format: (000) 000-0000.

Signature - I authorize Community Foundation of Acadiana (CFA) to draft my account as specified above.*