The Campaign to Change What It Means to Be Blind
Capital Campaign Pledge Intention

Home Address:_______________________________
City, State, and Zip:_______________________
Home Phone: ________________________________
Work Phone:_________________________________
E-mail address:_____________________________
Work Address:_______________________________
City, State, Zip:___________________________

To support the priorities of the Campaign, I (we) pledge the sum of $___________.

My (our) pledge will be payable in installments of $ __________ over the next ____ years (we encourage pledges paid over five years), beginning _____________, on the following schedule (check one): __ annually, __ semi-annually, __ quarterly, __ monthly

I (we) have enclosed a down payment of $ ________________

___ Gift of stock: _____________________ shares of _____________

___ My employer will match my gift.

Please list (my) our names in all campaign reports and on the Campaign Wall of Honor in the appropriate Giving Circle as follows:

__ I (We) wish to remain anonymous.

Signed: ________________________________ Date: __________________