For PDF format
(free
reader available), click
here. Otherwise, follow instructions below:
Please print this page, complete the form, sign
it, and mail it to:
Tracey Sperry, Director of Development & Research
Scleroderma Foundation
300 Rosewood Drive, Suite 105
Danvers, MA 01923 |
 |
| Installment
Giving Program Enrollment Form |
| Personal Information: |
| Name: _____________________________________________________________________ |
| Address: ___________________________________________________________________ |
| City: ______________________________ State: __________________
Zip: ____________ |
| Home Phone: _______________________ Work Phone:
____________________________ |
| Email: ________________________________ |
| I will make an ongoing monthly gift of $________
per month. |
| I will make a total gift of $_________ in _______
monthly installments of $_____________ |
| Make my installments via Automatic Credit Card
payments: |
| Mastercard VISA |
| Card number: __________________________ Expiration
Date: _______________ |
| Signature: __________________________________________________________________ |
| My gift is given (check one): in honor of
in memory of |
| Name: ____________________________ Please notify:
____________________________ |
Donors of $25 or more annually can be acknowledged
as members:
I am not interested in member benefits. |
