Gift / Pledge Form

I/we want to help hard working students realize their dreams with a contribution in the form of a:

Gift (enclose check money order or credit card information on the form below)
Pledge (Be sure to include date pledge will be paid)

Amount: Date: Pledge payment date:

Check if any of the following information is new

Name:

Address:

City: State:Zip:

Phone: Fax: Email:

Name (as it appears on the card)

Address:

City: State:Zip:

Card Type: Visa Mastercard Discover American Express

Amount

Card Number Expiration date

Signature: _____________________________________ Date of contribution:

(Print and Mail only please)
Alice Lloyd College
Institutional Advancement
100 Purpose Road
Pippa Passes, Ky 41844