Donation Pledge Clemson Page 2
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1
2APPLICATION
Name:________________________________________________________________________ IPTAY No.:___________________________
Mailing Address:____________________________________________________________________________________________________
City:_____________________________________________________ State:___________________ ZIP:_____________________________
Home Phone:_____________________________________ Business Phone:___________________________________________________
Cell Phone:_______________________________________ Employer:________________________________________________________
Email Address:____________________________________ IPTAY Representative Name and No.:________________________________
CLEMSON GRADUATION MONTH/YEAR
PLEASE CIRCLE: December 2011 / May 2012 / August 2012
Donor Level:
Purple Donor FREE
Champion Donor $70
Orange Donor $35
Tiger Donor $140
PLEASE CIRCLE: December 2010 / May 2011 / August 2011
Donor Level:
Purple Donor $35
Champion Donor $175
Orange Donor $87.50
Tiger Donor $350
PLEASE CIRCLE: December 2009 / May 2010 / August 2010
Donor Level:
Purple Donor $70
Champion Donor $350
Orange Donor $175
Tiger Donor $700
PLEASE CIRCLE: December 2008 / May 2009 / August 2009
Donor Level:
Purple Donor $105
Champion Donor $525
Orange Donor $262.50
Tiger Donor $1,050
Method of payment:
Check (Payable to IPTAY)
VISA
MasterCard
Discover
AmEx
Amount enclosed: _______________________________________________________________
Credit card number: _____________________________________________________________
Expiration date: _________________________________________________________________
Name as it appears on card: ______________________________________________________
Signature: ______________________________________________________________________
IPTAY, P.O. Box 1529, Clemson, SC 29633
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