Please
fill out the following form and mail to us at our
address below:
Belgrade Regional Conservation Alliance
PO
Box 250
Belgrade Lakes, ME 04918
Donation/Pledge
Form
|
| Personal
Information: |
|
| Ms./Mr.
____ |
First
Name ___________________ MI_____ |
Last
Name _____________________ |
| Phone
Number: |
Home
( ) ____________________ |
Work
( ) _______________________ |
| Permanent
Address ____________________________________________________________________ |
| City
____________________________________ |
State
_______ Zip Code __________ |
| Summer
address (if different) ____________________________________________________________ |
| City
____________________________________ |
State
_______ Zip Code __________ |
| E-mail
__________________________________ |
|
|
|
| Business
Information (if donating as a Business or Organization):
|
| Organization
_____________________________________________ |
| Your
Position ____________________________________________ |
|
Business
Address _____________________________________________________________________
|
| City
____________________________________ |
State
_______ Zip Code __________ |
|
|
| Payment
Information: |
|
| Payment
type |
Donation
|
____
|
Donation
Amount:
$ _______________ |
| |
|
Pledge
|
____ |
Pledge
Amount:
$ _________________ |
| |
Pledge
payment to begin with an initial payment of $_________________
in Month/year___________ |
| |
The
pledge is to be fulfilled as follows: |
| |
$
________________________ |
in
month/year ____________________ |
| |
$
________________________ |
in
month/year ____________________ |
| |
$
________________________ |
in
month/year ____________________ |
| |
or
with the following terms: |
|
| |
______________________________________________________________________________________________
______________________________________________________________________________________________ |
| Payment
dedication |
|
If
the donation or pledge is made in the name or memory of another
person or organization, please check here ______
If you wish your gift to be anonymous, please check here _____ |
|
|
| Comments
_______________________________________________________________________________________ |
