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


Name: _____________________________________________________

Home Address: __________________________________________________

City, State, and Zip: __________________________________________________

Home Phone: ____________________________ Work Phone: __________________________

E-mail address: ________________________________________

Employer: ___________________________________________

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 5 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: __________________