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Dollars for Scholars                                    For Online Donation Instruction Review Click Here 

Corfu-Pembroke Chapter                                                                      For a PDF Printable Version Click Here

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