YES! I SUPPORT THE WHERE LEADERS RISE CAMPAIGN!
Jalen Rose Leadership Academy
A. YOUR PERSONAL INFORMATION
Name :
First Name
Last Name
Address :
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City, State, Zip:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number :
Format: (000) 000-0000.
Email :
example@example.com
B. MY GIFT
I am making a one-time gift
I am making a one-time gift of $
I am pledging $________________________________ to be paid over (check box below)
I am pledging $________________________________ to be paid over (check box)
1 year
2 years
3 years
C. FIRST PAYMENT
My check made payable to the Jalen Rose leadership Academy is enclosed.
Please charge my credit card in the amount of $___________________________
Please charge my credit card in the amount of $
Account #
Exp. Date:
-
Month
-
Day
Year
Date
CCV:
D. PAYMENT SCHEDULE
Choose Payment Schedule :
Annually - Please invoice me each year during the month of
Monthly - Please charge my credit card in equal installments of $
Quarterly - Please invoice me 4 times per year in equal installments on the 1st day of the following four months:
Please invoice me each year during the month of (only fill-out if you selected ANNUAL payments):
Annual payment month designation
Please charge my credit card in equal installments of $ (only fill-out if you selected MONTHLY payments):
Monthly payment amount designation
Please invoice me 4 times per year in equal installments on the 1st day of the following four months (only fill-out if you selected QUARTERLY payments):
Quarterly payment month designation
E. DECLARATION
RECOGNITION (CHECK ONE):
List my name as:
I would like my gift to be anonymous.
List my name as (only fill-out if you selected to list your name differently than it appears at the top of form):
List my name as
SPECIAL INSTRUCTIONS:
SIGNATURE:
For questions, please contact Rachel Decker Rachel@DetroitPhilantrophy.com (313) 782 - 3708
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