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Post Office Box 72
Corfu, New York 14036
First Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ MI: _ _ Last Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E-mail: ______________________________________________________________ Phone: (____) ______-______________
Street Address: _____________________________________________ City/State: _______________________ Zip: _______
Donation Amount:
- $31 (A dollar a day for a month)
- $365 (A dollar a day for a year.)
- Another Amount: [$_ _ _ _ .00]
Additional Information
My Donation is In Honor Of: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _
My Donation is in Memory of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ __ _ _ __ _ _ _ _ _ _ _ _ _ _ _
Gift Acknowledge Address for Honor/Memory Donations
_ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
May we publish your name in our Annual report? Yes -0 No -0
Your name will appear as listed,
if you would like it to appear differently, please not so: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I would like more information about Dollars for Scholars Yes -0 No -0
Corfu-Pembroke Dollars for Scholars Inc.
Post Office Box 72
Corfu, NY 14036-0072
