Women's Dermatologic Society

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

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.

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

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WDS Donation Form

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