Date:

Name:

Institution/Company Name:

Address:

City:

State:

Zip:

Country:

Phone: ()-

Fax: ()-

Email:

I want to support the ACPA Foundation with my gift benefiting:

The ACPA Educational Leadership Foundation Annual Fund:

Total Gift: $

Payment in Full: $

Monthly: $ for $ Months.

Quarterly: $

Other (information about each option is available on the ACPA Foundation website at http://www.acpafoundation.org/ ):

a. Diamond Honoree Campaigns:

Ken Bedini $
Carla Jones $
John Bishop $
Sandy MacLean $
John Bradac $
Gretchen Metzelaars $
Joanne Conlon $
Robert N. Page, Jr. $
Diane Cooper $
Lynne Reeder $
Connie Foley $
Kent Sampson $
Lynnea Halberg $
Michael Speros $
Merrit Henry $

Total Gift to Diamond Honoree $

b. Research/Publication Fund $
c. Gifts for Special ACPA Celebrations and Recognitions $
d. Donna M. Bourassa Mid-Level Management Scholarship Fund $
e. Multicultural Competence Institute $
f. Annuit Coeptis Reception and Dinner $
g. Jamaica Library Fund $
TOTAL GIFT $

I wish for my gift to be made In Honor of In Memory of

All names and gifts will be listed in the Foundation’s annual report and on the Foundation’s website unless otherwise noted below.

Please do not include my name in any list of contributors.

PAYMENT OPTIONS:

Enclosed is my check made payable to ACPA Foundation. 

Please charge my credit card:
Discover
MasterCard
Visa
American Express

(If using a credit card, it is suggested that the donor utilize the on-line donation form located at http://www.acpafoundation.org/)

Name on Card:

 
Address on Card (if different from above):


Account #:


3 Digit Security Code


Expiration Date


Signature

Please contact me. I wish to make a pledge.

Please contact me. I wish to make a gift of securities, life insurance policy, or planned gift (bequest).

I have already made arrangements for a deferred gift to the Foundation.

Gifts to the ACPA Foundation are tax deductible to the extent the law allows.

Please return this form and your gift to:

ACPA Foundation, P.O. Box 227, East Rochester, NY 14445

Please review the information entered and print the form before submitting.