Pledge Fulfillment Form

My Personal Information:
 
Name as I wish it to appear in acknowledgements: *
 
Winter (primary) address:   Summer address:

Street/PO Box:

*    
City:
*    
State/Region:
*    
Zip/Postal Code:
*    
Country:
*    
         
Phone:
*    
From:  Through: 
From:  Through: 
       
Email Address

:

*

 

 



My Pledge Payment:
Please accept my pledge payment of:
$ *
For year:
My contribution is also in memory of:
My contribution is also in honor of:
 

My Credit Card Information:

Name as it appears on credit card

:

*
     
Billing Address
:
Same as Winter (Primary) Address
     
Street/PO Box:
:
*
City
:
*
State/Region
:
*
Zip/Postal Code
:
*
Country
:
*
Phone
:
*
 

Card Details

   
Type of Card :  
MasterCard Visa American Express *
Card Number :  
*
CVV Code :  
*
Expiration Date :
 Month : *   Year : *
 
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The Unitarian Universalist Church on Nantucket is a 501(c)(3) not-for-profit corporation. Contributions are deductible to the full extent of applicable tax regulations.  Advice from your tax and legal advisors is recommended.