Name(s) *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

I/we intend to fulfill this pledge in: *

A one-time payment by check, appreciated securities, or other asset.

In equal installments paid annually.

In equal installments paid quarterly.

In equal installments paid monthly.

Other timetable or format.

For either a one time payment or equal installments, please indicate the date you anticipate making your first payment.

MM

DD

YYYY