2025 Pledge Donation Form

Whitetulip Health Foundation Pledged Donation Form

2025
Typical Annual Scholarship Tiers at Whitetulip:

Full Scholarship Amount(for married applicants): $18000

Scholarship Amount(for non-married applicants): $12000

Half Scholarship Amount: $6000

Quarter Scholarship Amount: $3000

One Brick(+USMLE Exam Fee) Amount: $1200

Half Brick Amount: $600
Donor Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Pledged Amount (Please enter the total amount you plan to pay in 2025, not monthly payment)
Name under which donor will donate (name of spouse, company, or alias)
Please enter your current profession.*
CheckZelleDirect Deposit through bankDonation through Website(0% Fee, Automatic Payments)Other
One-time12 monthly installments6 monthly installments3 monthly installmentsOther
For each installment, you will be making the following payment:
Jan.Feb.MarchApril
MayJuneJulyAug.
Sept.Oct.Nov.Dec.
Additional details: (Any details you would like to let us know, for example under what name should Whitetulip produce the donation receipts?)
Should be Empty:

Whitetulip Health Foundation Pledged Donation Form