Street ________________________________________

City__________________________________________

State & Zip____________________________________

Phone________________________________________

e-mail_________________________________

One-time gift amount:____________________

Multi-year Pledge:_______________________

2000_______________

2001_______________

2002_______________

2003_______________

2004_______________

Total Pledge Amount:_____________

Do you want a brick? (for donations or pledges of $500-$2,999)

Yes No

Name for brick_____________________________________________