Name: Last ________________________________ First _______________________________ Middle Initial _____

Address: ____________________________________ City: _________________ State: ______ Zip: ______

Phone Number(s): _______________________________ Email: __________________________________

Todays Date: ____________________________

Enclosed is a tax deductible gift of: $25 ______ $50 ______ $100 ______ Other Amount $ _____________

This contribution is in honor of ____ or memory of ____: (Name party) ____________________________________

Would you like to pledge an additional amount for the next 2 years? Yes _____ if so, amount $ ___ No ____