IMPACT CIRCLE PLEDGE FORM
Donor Information
Salutation
Mr. & Mrs.
Mrs.
Mr.
Ms.
Dr. & Mrs.
Dr.
Dr. & Dr.
Other
First Name
*
Last Name
*
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name to use for all recognition
*
This name will be used on the website, annual report, social media, etc.
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Gift Information
Full Gift Amount, please note this pledge is for the generous donation of $100k or more
*
Total Gift Amount
Amount/Payment $
*
Gift Amount Frequency
Pledge Frequency
*
Monthly
Quarterly
Annually
Pledge method
*
Check
ACH
Pledge Length
*
5 Years
7 Years
10 Years
I/We agree to give the stated amount annually for the selected number of years to the FICPA Scholarship Foundation. This is an unrestricted gift unless otherwise noted.
*
Date
*
-
Day
-
Month
Year
Date
Additional Comments
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