Clone of H.E.A.L. Mississippi Contributor Partnership Form

Legacy Partnership Pledge
Partner's Name
(Business, Organization or Individual)
Name of Contact Person

First NameLast Name
Title
E-mail
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legacy Partnership Levels:
prevnext( X )
Legacy Partner Level 1
$10,000.00



Legacy Partner Level 2
$15,000.00



Legacy PartnerLevel 3
$20,000.00



Legacy Partnerlevel 4
$25,000.00



Legacy PartnerLevel 5
$50,000.00



Total

$0.00
Check Payment Information:

Check: Make payable to H.E.A.L. Mississippi
Please remit check payments to:

H.E.A.L. Mississippi

PO Box 12402

Jackson, MS 39236
Additional Comments or Requests:
Legacy Partnership Agreement:

By submitting this form, the partner agrees to the terms outlined in the partnership levels and commits to providing the selected partnership amount. Payment can be made over the course of time.
Authorized Signature:

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Date Signed

MonthDayYear
Date
Should be Empty:

Legacy Partnership Pledge