Pledge Form
 
(Print and Complete)

 Prevent the suffering of cancer patients who have not

 been fully informed of all available options and

 further awareness of Integrative Treatment.   


Donor Information  

Name____________________________________________



Billing address_______________________



City___________________



State_______



ZIP Code_________



Telephone (home)_________________



Telephone (business)_______________



Fax________________



E-Mail___________________

 

Pledge Information I (we) pledge a total of _______________ 


to be paid: 

 ____ now  ____ monthly  ____ quarterly  ____ yearly.


I (we) plan to make this contribution in the form of:


 ____ cash  ____ check ____ credit card  ____ other.

Credit card type__________________________________



Credit card number________________________________

Expiration date____/_______



Authorized signature__________________________________________



Gift will be matched by  ________________________________ 

(company/family/foundation).


 ____ form enclosed  ____ form will be forwarded

Acknowledgement Information Please use the following name(s) in all 

acknowledgements:

 

 ____ I (we) wish to have our gift remain anonymous.



Signature(s)_________________________ Date___________________



Please make checks, corporate matches, or other gifts payable to:



QFCC Corp