ACMS - American College of Mohs Surgery

Please complete this section for Annual Pledge length:

* I understand that I will be contacted by the ACMS Foundation to set up a payment schedule. I plan to pay this pledge over:

2 years 3 years 4 years 5 years

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:

every month for 12 months (_/total)

every month for 24 months (_/total)

every month for 36 months (_/total)

Consent and Authorization

I consent and authorize my bank/credit card to make recurring monthly payments until I notify the ACMS Foundation otherwise. First charge to occur on the selected start date. I understand that I may cancel or change my recurring gift at any time by notifying the ACMS Foundation at (414) 347-1103. 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 annually.

Gift Designation

Patient Donor

Payment Information

* Card Type:

American Express MasterCard Visa

* Card Number:

* Exp. Date:

* CVV #:

* Name as it appears on card:

* Address:

* City:

State/Province:

* ZIP:

* Country:

This Gift is

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 (email)

A personalized message can be included with your card (300 Characters maximum)

ACMS Members

ACMS Foundation Online Donation Form

Information

Gift Amount

Frequency

Gift Designation

Patient Donor

Payment Information

This Gift is