... for the Future of WDS!     

Rose Bouquet Pledge Form

To make your pledge using a check, please download the PDF form

1. DONOR INFORMATION

Date: (required)
Name: (required)
Billing Address: (required)
City: (required)
State: (required)
Zip: (required)
Telephone: (required)
Fax:
E-Mail Address: (required)

2. PLEDGE INFORMATION

Total amount pledged: (required)

$500 White Rose
$1,000 Yellow Rose
$2,500 Pink Rose
$5,000 Red Rose
$10,000 Blue Sapphire Rose
$25,000 Diamond Rose
$35,000 Emerald Rose
Other amount not listed here
(Payable in full immediately)
To be paid: (required)

Immediately paid in full
2 yearly installments each totaling 50% of pledge
5 yearly installments each totaling 20% of pledge
Other amount not listed here:
 Amount $ per
(Payable in installments)


My donation is: (optional)
 in honor of    in memory of    in tribute to    in honor of my mentor    n/a

Name and address of friend, colleague, mentor, loved one:
Name:
Address: 

3. PAYMENT INFORMATION

Payment Method: (required)
 Credit Card - After clicking the 'Submit' button below you will be asked for your credit card information
          Cards accepted: American Express, Mastercard, Visa

4. ADDITIONAL COMMENTS & INSTRUCTIONS


PLEASE NOTE:
Your charitable donation to the WDS is 100% tax deductible!
The Society’s Federal Tax I.D. number is 20-0084052.
If you have questions on pledge donations or other forms of giving, contact the WDS at:
1-877-WDS-ROSE (937-7673) or wds@womensderm.org


PDF DOWNLOAD: If you prefer to download the form and fax/send

Please return completed form to:
Women’s Dermatologic Society
700 N Fairfax St. Suite 510
Alexandria, VA 22314

FAX: (571) 527-3105
PHONE: (571) 527-3115