Printable donation form

Donor Name:___________________________________________
Donor Mailing Address:___________________________________
______________________________________________________
Donor Phone:___________________________________________
Donor Email:___________________________________________

Enclosed is a donation of $___________________
____ This donation if for the New Hazlett Theater
____ This donation if for cityLIVE! programming at the New Hazlett Theater

I am making a donation of $_____________, which amount I authorize The New Hazlett Theater to charge to my credit card listed below.
____Visa ____Mastercard ____American Express

Cardholder’s Name: ______________________________________________________
Credit Card #: ______________________________________________________
Expiration Date: ______________________________________________________
Signature of Cardholder: ______________________________________________________
Today’s Date: __________________

I pledge $_______________, of which $___________ is enclosed and the balance payable as follows: #____ payments of $_______each by ______(final payment date)

My gift will be matched by_________________________________
(Attach matching gift form)
My gift is in recognition of ________________________________
I would like my gift to remain anonymous ______