Make a Multi-Year Pledge - Give

Print Form
Multi-Year
Pledge Form
5154
Email Form
This form allows you to create a multi-year pledge to
Purdue University and set up a schedule to receive
reminder notices by mail. If you desire to set up
automatic payments by credit card or debit card, select
“Set Up Recurring Gifts” instead of this form.
Gift Information:
I/We pledge to give $_____________ (excluding any anticipated matching gifts).
Designation (list dollar amount of each payment):
$____________ The Fund for Purdue (018605)
$____________ College/School (specify) _________________________
$____________ Department (specify) ____________________________
$____________ Other (specify):_________________________________
Purdue Foundation will mail pledge statements based on the schedule you determine is best for you.
You will be able to pay by credit card or debit card.
Frequency of payments (select one) ☐ Monthly ☐ Quarterly ☐ Semi-annually ☐ Annually
Duration of payments (number of years) ________________
Start date____________________
Signature_________________________________________
Date________________________
Signature_________________________________________
Date________________________
Optional Payment
Enclosed is the first payment of $__________________
Credit or Debit Card
I authorize Purdue University to charge $____________ to my:
☐Visa ☐MasterCard ☐Discover ☐American Express
Card Number:________________________ Exp. Date: ___/___ CVV:_______
Printed name as it appears on card:______________________________________
Billing Address: ____________________________________________________
☐Same as mailing address (please supply below)
Signature:____________________________________ Date:_______________
Matching Gifts
☐I anticipate that my gift will be matching by (specify company) _______________________________
Donor Information
Name ______________________________________
Street Address _______________________________
City _______________________________________
State _______________
Zip Code ________
Telephone __________________________________
E-mail _____________________________________
Alumna/us? ☐Yes ☐No Year Graduated_______
Name at Graduation:___________________________
Spouse Information
Spouse Name________________________________
E-mail______ _______________________________
Alumna/us? ☐Yes ☐No Year Graduated_______
School ______________________________________
Name at Graduation ___________________________
Mail form to: Purdue Foundation, 403 West Wood Street, West Lafayette, IN 47907-2007
Contact us at: (800) 319-2199 or [email protected]
EA/EOU Produced by Purdue Marketing and Media
10.UDO.3.029a