DONATION FORM
 Yes, I want to help students stay in school and prepare for life!
 Donate with confidence.
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* Denotes Required Information
Donor Information
* Title:  Enter here if not listed. 
* First Name or Initial:
Middle Name or Initial:
* Last Name:
Suffix:
Company Name:
* Address Line 1:
Address Line 2:
* City:
* State:
* Zip Code:
Home Phone:
Business Phone:
* Email:
Donation Information
Levels of Giving:
$1-$99 Friend
$100-$249 Supporter
$250-$499 Advocate
$500-$999 Believer
$1000-$4999 Champion
$5000-Up Hero
* Donation Amount:
I work for a matching gift company and will submit my form to:
Anonymous?  Do not print my name in agency publications.
All contributions are fully tax deductible within the limits of federal and state laws.
Payment Information
Credit Card
Credit Type:  Mastercard    Visa
Cardholder's Name:
Credit Card Number:
example: 4111222233334444
no dashes
Expiration Date: /
Card Security Code*:
*(On Visa/MC/Discover, the 3-digit number on back of card; On Amex, the 4-digit number on front of card)
Check
  Checks made payable to Communities In Schools. Please print and mail form with payment to:
Communities In Schools
601 East 5th Street #300
Charlotte, NC 28202
Bill Me
Please Bill Me:  Quarterly    Annually ( Month of  )
Stock or Other Securities
  Please contact Leigh Bogucki at
(704) 943-9440
Designation Information
Gifts to Communities In Schools are a meaningful way to
remember someone special. To make your gift in honor
or memory of someone, please complete the following:
In Memory of 
In Honor of 
Please send notice of this gift to:
Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Thanks for joining our effort to help students choose success!

If you have any questions, please email Romy Graham at
rgraham@cischarlotte.org or call (704) 943-9446




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