WDS Donation Form Information * Name: * Address: * City: State: * ZIP/Postal Code: * Country: * Phone: * Email: Gift Amount $1000 $500 $250 $125 Other Amount (minimum $10) * Amount to Charge: $ .00 Frequency One-time Gift Recurring Gift: A pledge of the above amount over the time period of your choice. Please complete this section for Recurring Gift: * Start Date: (MM/YYYY) * Bill my credit card: 1st of the Month 15th of the Month * Number of Months: for 12 months (_/month) for 24 months (_/month) for 36 months (_/month) Other * Number of Months: (_/month) Consent and Authorization I consent and authorize my bank/credit card to make recurring monthly payments until I notify the Women’s Dermatologic Society (WDS) otherwise. First charge to occur upon the submission of this form. I understand that I may cancel or change my recurring gift at any time by notifying WDS at (414) 918-9887. A record of each payment will appear on my monthly bank or credit card statement and will serve as my monthly receipt. A letter showing cumulative donations for the calendar year will be sent each February. Gift Designation Legacy Fund Academic Research Disaster Relief International Journal of Women’s Dermatology (IJWD) Young physicians General WDS Donation This Gift is A General donation In Honor of (please complete next section) In Memory of (please complete next section) In Tribute to (please complete next section) In Honor of my Mentor (please complete next section) Please complete this section for Honor and Memorial gifts: The special person or occasion: You can choose to send your card to two (2) people Card Recipient Name #1 Address 1 City 1 State/Province 1 ZIP/Postal Code 1 Country 1 Telephone 1 Card Recipient Name #2 Address 2 City 2 State/Province 2 ZIP/Postal Code 2 Country 2 Telephone 2 Sent by (name) A personalized message can be included with your card 300 Characters maximum Payment Information * Card Type: American Express MasterCard Visa * Card Number: * Exp. Date: 010203040506070809101112 / 2018201920202021202220232024202520262027202820292030 * CVV #: Click to use same name and contact information as above * Name as it appears on card: * Address: * City: State/Province: * Zip: * Country: Continue Thank you for your generous donation.