Umaine Center on Aging Pledge Form

UMaine Center on Aging Pledge Form

If requested, upon completing this form, a representative from the University of Maine Center on Aging will be in contact with you to ensure the process is followed through to your exact specifications. Please return completed form to University of Maine Center on Aging, 5723 Donald P. Corbett Business Building, Orono, Maine 04469-5723.

Donation Amount: $

Name (last, first):

UMaine class of (if applicable):

Address:

City:

State:

Zip:

Phone:

E-mail address:

Please bill my credit card

I have enclosed a check

Type of credit card (MasterCard, Visa, or Discover only):

Name on credit card:

Credit card number:

Expiration date:

This is a gift:

in honor of

in memory of

Name:

Please send acknowledgment of gift to:

Comments: