| DONOR
INFORMATION |
| FIRST
NAME: |
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| LAST
NAME: |
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| ADDRESS:
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| CITY:
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| STATE:
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| ZIP:
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| E-MAIL:
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DAY
PHONE:
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EVENING
PHONE:
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CREDIT
CARD TYPE:
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CREDIT
CARD NUMBER:
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| CREDIT
CARD SECURITY CODE: |
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CREDIT
CARD EXPIRATION DATE:
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| DONATION
INFORMATION |
Amount of Donation:
(The Society of Repeat Defenders: $1,500 & above) |
$25,000
$15,000
$10,000
$5,000
$3,000
$1,500
$1,000
$750
$500
$250
$100
$50
$25
Other
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Please
confirm donation amount:
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$
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I do not wish to
receive any benefits in return for this gift and will deduct the full amount
of my contribution.
I wish to give anonymously.
I will be sending
you a matching gift form shor tly.
I wish to pay my
pledge in up to three installments, please send me reminders on the following
dates. (Donations
of $1,000 or more only —full payment due by 06/30/12): |
| Installment
Dates: |
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| Gifts
of $500 or more will receive recognition in the NYTW program for one year.
I would like my name to appear as follows: |
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