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Board of Trustee
Former Board of Trustee
Friend of School
Year of Graduation
(4 digits, if applicable)
Address Line 1
Address Line 2
What prompted you to make this gift?
Please indicate how you would like your name(s) to be recognized in our Donor Listings.
I wish for my name to remain anonymous
I would like to contribute:
Total Donation Amount (US$)
Please debit my credit card
with payment/installments of
Please keep my credit card details on file for any installment payments
I would like to pledge my support
Credit Card Number
Name on Card
Child's Full Name & Grade for Student Account
(if billed to Student Account)
ACPHS will send appropriate reminders
I would like this gift to be directed to:
Geno Germano Challenge
Moving Forward Capital Campaign
Athletics(donations can be directed to specific programs/teams; please specify SPECIAL INSTRUCTIONS section below)
ACPHS Academy Fund
Professional Development Project
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
Books & Periodicals
Prizes and Gifts
Ann Steffens Memorial Scleroderma Research Fund
Don Seifert Challenge - Library Fund
Other:Please specify in SPECIAL INSTRUCTIONS below-choose from this
Please indicate whether your employer or your spouse's employer will match your gift.
, matching form will be sent later
, 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:
Please send an acknowledgment of my gift to:
Any special instructions we should know?
Thank You! Your receipt will be mailed to the above address.
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