ACC Network Donation form

Please print legibly

Enclosed is my gift of: $___________

I would like to use my:

(Please circle one) Visa MasterCard American Express

Account Number:_________________________ Card Expiration Date:_____________

Signature of Cardholder:_____________________________

Name: ________________________________

Address:________________________________

________________________________

Checks should be made payable to the ACC Network

Is your gift a memorial or tribute? A letter advising of your gifts, without reference to amount, may be sent to the person(s) you designate:

___ Yes, please send a letter acknowledging the gift.

___ Please notify the person(s) below, but I wish to remain anonymous.

My gift is in:

______ Memory of (Name) _____________________________________________

______ Honor of (Name) ______________________________________________

Send acknowledgement to:

Name: _______________________________________

Address: _____________________________________

_____________________________________________

Please mail to: ACC Network; 5749 Merrill Hall Room, 118; University of Maine; Orono, ME 04469-5749; USA

Last revised on: 04/12/2006