Pledge Form - Beyond Cancer Campaign

Pledge

I want to make a difference in our community by pledging my support to the Sentara Brock Cancer Center with a total gift of:

Amount

$

Is the gift $5,000 or above?

Recognition

I prefer to remain anonymous

NoYes

Name as you would like it to appear on the donor wall:

(for gifts of $5000 & above)

I am interested in the following naming opportunity:

(Naming options start at $10,000)

Given over the next

years

Amt/Year:

$

Right now, all gifts designated to the 3D Mammography Mobile Unit Fund will be matched dollar-for-dollar, up to a total of $125,000. Double your impact with a gift to this fund today!

Please designate my gift as:

Are you a Sentara Employee

NoYes

Preferred Payment Method:

Send Annual Pledge RemindersPayroll DeductionGifts of $5,000 or more qualify for payroll deduction

Amt Per Pay Period

Number of Months

Send Annual Pledge Reminders?

YesNo

Date when I intend to begin pledge installments:

Honor/Memorial

Is this donation in honor of or in memory of someone?

Name:

Title

First Name

MI

Last Name

Suffix

Send notification?

Yes (Mail)No

Send Notification to:

Title

First Name

MI

Last Name

Suffix

Phone

Email

Mailing Address Line

City

State

Postal Code

Contact Information

Salutation

First Name

Middle Name

Last Name

Suffix

Address

City

State

Zip/Postal Code

Phone

Please provide your Sentara email & ID below:

Email

Employee ID

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Contact Information