DONOR INFORMATION (please type or print)

DATE:______________

NAME ________________________________________________________________________________

ADDRESS _____________________________________________________________________________

CITY___________________________STATE __________________ ZIP___________________________

TELEPHONE(home) _________________ (business) ______________ (cell) _________________________

EMAIL ____________________________________ FAX _______________________________________

PLEDGE INFORMATION
I(we) hereby contribute cash and/or assets to St. Mary’s Center.
I(we) pledge a total of $ ___________________ enclosed _____________ pledged ____________________
I(we) wish to have this donation spread over 1 2 or 3 year(s) other____________
Please bill me beginning ______________________and thereafter(circle one) monthly/quarterly/ yearly
My gift will be matched by _______________________________________(company/foundation/family)

Form enclosed
Form will be forwarded

I (we) would like information on including St. Mary’s Center in my (our) will/estate planning
I (we) plan to make my (our) contribution in the form of (circle all that apply) cash/ check/ charge/ stock/ property
other__________________________________________________________________________________
Please charge my credit card: (circle one) Visa/ Mastercard/ American Express
Card # ___________________________________ Expiration Date ________________
Authorized Signature _______________________________________________________________

LISTING (Donors will be recognized in campaign materials unless an anonymous gift is requested.)
Please use the following name(s) in all acknowledgements: ___________________________________________
Signature(s)__________________________________________________________Date________________
PLEASE MAKE CHECKS, CORPORATE MATCHES & STOCK TRANSFERS PAYABLE TO:

Mail your pledge to:
St. Mary’s Center
925 Brockhurst Street
Oakland CA 94608

Questions? Please Contact Carol Johnson, Executive Director of St. Mary’s Center
Telephone 510-923-9600 x 223
FAX 510-923-9606
Email cjohnson@stmaryscenter.org