International Catacomb Society
Bridging Disciplines • Supporting Scholarship • Connecting the Public
Donor Information (please print or type)
Name
Billing address
City, ST Zip Code
Phone 1 | Phone 2
Pledge Information
I (we) pledge a total of $____________________ to be paid: ☐now ☐monthly ☐quarterly ☐yearly.
I (we) plan to make this contribution in the form of: ☐cash ☐check ☐credit card ☐other.
Credit card type | Exp. date
Credit card number
Authorized signature
Gift will be matched by (company/family/foundation)
☐form enclosed☐form will be forwarded
Acknowledgement Information
Please use the following name(s) in all acknowledgements:
☐I (we) wish to have our gift remain anonymous.
Signature(s)
Date
Please make checks, corporate matches,
or other gifts payable to:
International Catacomb Society
7 Whittier Pl Ste 108 PMB 211
Boston, MA 02114