ETHAN
Pledge
Form
I
would like to show my support of ETHAN with a gift of:
$__________
1.
Donor Information:
Print
Name_____________________________________________________________
Address_________________________________________________________________
City______________________________________State___________Zip____________
Home Phone
__________________________Work Phone ________________________
Email Address
___________________________________________________________
(Optional)
2.
Gift Options: (please
indicate your choice of payment)
��
PLEDGE
$____________ (please bill me)
��
CHECK ENCLOSED
in the amount of
$_____________
(payable
to ETHAN)
��
Please charge my
CREDIT CARD
$________________
Type of Card:
��
Visa
��
MasterCard
��
American Express
��
Discover
Total Gift -OR-
Payment(s) of $ _____________ in each circled month:
Jan, Feb, Mar, Apr, May, June, July, Aug, Sept, Oct, Nov, Dec
Credit Card Information
(required):
Name as it appears on Credit
Card:
__________________________________________
Mailing Address of Credit Card
Statement:
___________________________________
_______________________________________________________________________
Credit Card #:
______________________ Expiration
MMYY:
___/_______
Security Code
(last three numbers and, or digits on back of card) _________
Please
return to:
ETHAN (
117
For further information call (409) 384-2099
Or visit
www.ethannetwork.org