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Donor Information
* = required
Full Name *
Affiliation *
Year of Graduation     (4 digits, if applicable)
Address Line 1 *
Address Line 2  
City *
State/Province *
Zip/Postal Code *
Country  
Daytime Telephone *
Email *
What prompted you to make this gift? *
Recognition
Please indicate how you would like your name(s) to be recognized in our Donor Listings.
 
I wish for my name to remain anonymous
Payment Information
I would like to contribute:
Total Donation Amount (US$) *
Please debit my credit card *
Annually  
Quarterly  
Monthly         with payment/installments of   (Amount US$)
One-time Gift  
   
Please keep my credit card details on file for any installment payments
Payment Type *
Directed Donations
* I would like this gift to be directed to:
ACPHS Annual Fund (Greatest Need)
Community Campaign
Financial Aid & Student Scholarships
Academic Programs
Athletics Fund(donations can be directed to specific teams) (Please Specify)
Parent Fund
Professional Development Project
Professor James Anderson Humanitarian Award
Class of 2014 Legacy Scholarship Fund-Albany Campus
Choose from the listing of Alumni and Friends Scholarship Funds click here for listing
Other (Please Specify)
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 at 518.694.7316 OR email to alumni@acphs.edu

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


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

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