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: $ 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 * Please note, tickets to the Legacy Celebration are not included with this donation and must be purchased separately. Legacy Fund General WDS Donation Other This Gift is A General donation In Honor of (please complete next section) In Memory of (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: Visa MasterCard American Express *Credit Card Number *Exp Month 010203040506070809101112 *Exp Year 2021202220232024202520262027202820292030203120322033 *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.
