The Campaign To Change What It Means To Be Blind

Capital Campaign Pledge Intention

Name ______________________________________________________

Home Address _______________________________________________

City ___________________________ State _________ ZIP ___________

Home Phone __________________ Work Phone ____________________

E-mail address _______________________________________________

Employer ___________________________________________________

Work Address ________________________________________________

City ______________________ State _________ ZIP ________________

To support the priorities of the Campaign, I (we) pledge the sum of $___________.

My (our) pledge will be payable in installments of $ __________ over the next

____ years (we encourage pledges paid over 5 years), beginning _____________,

on the following schedule (check one):

                    __ annually       __ semi-annually           __ quarterly      __ monthly

I (we) have enclosed a down payment of $ ________________

___ Gift of stock: _____________________ shares of __________________

___ My employer will match my gift.

Please list (my) our names in all Campaign Reports and on the

Campaign Wall of Honor in the appropriate Giving Circle as follows:

_____________________________________________________________________

__ I (we) wish to remain anonymous.

Signed: ________________________________ Date: __________________