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Donor Information
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Full Name *
Affiliation *
Year of Graduation     (4 digits, if applicable)
Address Line 1 *
Address Line 2  
City *
State/Province *
Zip/Postal Code *
Daytime Telephone *
Email *
What prompted you to make this gift? *
Please indicate how you would like your name(s) to be recognized in our Donor Listings.
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Payment Information
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Total Donation Amount (US$) *
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Monthly         with payment/installments of   (Amount US$)
One-time Gift  
Please keep my credit card details on file for any installment payments
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Directed Donations
* I would like this gift to be directed to:
Geno Germano Challenge
Annual Fund
Moving Forward Capital Campaign
Athletics(donations can be directed to specific programs/teams; please specify SPECIAL INSTRUCTIONS section below)
ACPHS Academy Fund
Parent Fund
Professional Development Project
Vermont Campaign
Class of 2013 Legacy Scholarship-Vermont Campus
General Scholarship Fund
Class of 2013 Legacy Scholarship Fund-Albany Campus
Class of 2014 Legacy Scholarship Fund-Albany Campus
General Research Fund
Biomedical/Cytotechnology Program
Books & Periodicals
Prizes and Gifts
Ann Steffens Memorial Scleroderma Research Fund
Don Seifert Challenge - Library Fund
In memory of Anthony “Tony” Chiffy ’60
Other:Please specify in SPECIAL INSTRUCTIONS below-choose from this list
Matching Gifts?
Please indicate whether your employer or your spouse's employer will match your gift.
  Yours | Spouse | Organization Name(s)
Yes, matching form will be sent later
No, matching not available  
Please fax your form to Bill Jabour Director of Annual Giving and Alumni Relations in care of Albany College of Pharmacy and Health Sciences, Office of Institutional Advancement, 106 New Scotland Avenue, Albany, NY 12208.

In Honor / Memory of
I would like this gift to be in Honor / Memory of:
      In Honor   In Memory
  Please send an acknowledgment of my gift to:
Special Instructions
Any special instructions we should know?

Thank You! Your receipt will be mailed to the above address.

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