WDS Legacy Donation Form - Thanks for Donating Click Here to see the Levels of Giving. Wonder how close you are to moving up to the next level?Click Here to request your current donation amount today! You could be one donation away from a newly designed donor pin by our very own Janet Hickman, MD! Information * Name: * Address: * City: State: * ZIP/Postal Code: * Country: * Phone: * Email: Donation Amount $2500 $1000 $500 $250 $125 Other Amount (minimum $10) * Amount to Charge: $ .00 If you would like to make this a Recurring Donation* please fill out one of the options below *(A pledge of a specific amount over the time period of your choice.) No Thanks, I'd rather do a One-time Donation. Complete this section for Recurring Monthly Donation: * Start Date: (MM/YYYY) * Bill my credit card: 1st of the Month 15th of the Month * Number of Months: for 12 months (_ - total) for 24 months (_ - total) for 36 months (_ - total) Other * Number of Months: (_ - total) Complete this section for Recurring Annual Donation: * Number of Years: for 1 year (_ - total) for 2 years (_ - total) for 3 years (_ - total) for 4 years (_ - total) for 5 years (_ - total) Consent and Authorization I consent and authorize my bank/credit card to make recurring 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 donation 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. This Donation 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 donations: 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 / 2019202020212022202320242025202620272028202920302031 * 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.