Capital Campaign Donation (Credit Card) Step 1 of 4 25% 1. Your InformationName* First Last Is this donation also from a spouse/partner?*YesNoSecond Donor Name First Last I am a(n)*AlumniParentGraduation YearChild's NameChild's Graduation YearEmail* Cell Phone 2. Capital GiftMaryland Hillel relies on the donations of alumni like you to run its programs and initiatives. We ask that your capital campaign gift be over and above what you have given annually in the past. If you are not an annual campaign donor, Hillel requests your permission to designate 10% of your gift to its annual campaign.I am:*An existing annual donorNot an existing annual donorMy capital gift is for:*General GiftNaming OpportunitiesAlumni BrickGeneral Gift*One Time GiftMonthly GiftGeneral Gift Amount* Monthly Gift Amount* Naming Opportunity- I would like to be contacted by:*Phone CallEmailI would like to pay an existing pledge*YesNoPay an existing pledge:* Naming Opportunity- Please indicate desired size of gift, and what you wish to name (not guaranteed until finalized with Hillel)*Alumni Brick*$5400 (12"x12") 6 lines of text/ 15 characters per line and recognition on naming wall$3600 (12" x 12") 6 lines of text/ 15 characters per line$1800 (8" x 12") 4 lines of text/ 15 characters per line$1000 (8" x 8") 2 lines of text/ 13 characters per line$5400 (12"x12") 6 lines of text/ 15 characters per line and recognition on naming wall*Full AmountFive Year PlanMonthlyWhat would you like your break to say? (6 lines of text/ 15 characters per line)$3600 (12"x12") 6 lines of text/ 15 characters per line*Full AmountFive Year PlanMonthlyWhat would you like your brick to say? (6 lines of text/ 15 characters per line)$1800 (8" x 12") 4 lines of text/ 15 characters per line*Full AmountFive Year PlanMonthlyWhat would you like your brick to say? (4 lines of text/ 15 characters per line)$1,000 (8" x 8") 2 lines of text/ 13 characters per line*Full AmountFive Year PlanMonthlyWhat would you like your brick to say? (2 lines of text/ 13 characters per line) 3. PaymentTotal $0.00 Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name My gift is*In Honor of SomeoneIn Memory of SomeoneNot in Honor or in Memory of SomeoneName of HonoreeKeep my gift anonymous*YesNoMy employer offers a matching gift programYesNoName of EmployerEmployer's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Data SourceLGL Form ID
