Fillable Purdue Uni Gift Form printable pdf download

Purdue Uni Gift Form

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Gift Form

5153

Gift Information:

Enclosed is my/our gift of $__________.

Designation (list dollar amount of each payment):

$____________ The Fund for Purdue (018605)

$____________ College/School (specify) _________________________

$____________ Department (specify) ____________________________

$____________ Other (specify):_________________________________

Payment Authorization

Credit or Debit Card

I authorize Purdue University to charge $____________ to my:

☐Visa ☐MasterCard ☐Discover ☐American Express

Card Number:________________________ Exp. Date: ___/___ CVV:_______

Printed name as it appears on card:______________________________________

Billing Address: ____________________________________________________

☐Same as mailing address (please supply below)

Signature:____________________________________

Date:_______________

Matching Gifts

☐

I anticipate that my gift will be matching by (specify company) _______________________________

Donor Information

Spouse Information

Name ______________________________________

Spouse Name________________________________

Street Address _______________________________

E-mail______ _______________________________

City _______________________________________

Alumna/us? ☐Yes ☐No

Year Graduated_______

State _______________

Zip Code ________

School ______________________________________

Telephone __________________________________

Name at Graduation ___________________________

E-mail _____________________________________

Alumna/us? ☐Yes ☐No

Year Graduated_______

Name at Graduation:___________________________

Mail form to: Purdue Foundation, 403 West Wood Street, West Lafayette, IN 47907-2007

Purdue Uni Gift Form

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