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PAFP Foundation Pledge Form
PLEDGE INFORMATION
First Name:
Last Name:
Street Address:
City, State and Zip Code:
Preferred Phone No.:
Preferred Email Address:
PAFP/F Affiliation:
Total Gift/Donation Amount:
Gift Allocation:
 
PLANNED GIVING
I am interested in including the Foundation in my estate planning, such as leaving a donation in my will or making a deferred gift.
Please send me more information:
Please have a Foundation representative contact me:
 
PAYMENT OPTIONS
I am making full payment now:
Contact me about additional payment options:
Payment Type:
Credit Card Number:
Credit Card Security Code:
Credit Card Expiration Date:
Name on Credit Card:
Billing Street Address:
Billing City, State and Zip Code:
Billing Phone No.:
 
Please make all checks payable and deliver to:
PA Academy of Family Physicians Foundation
2704 Commerce Drive, Suite A
Harrisburg, PA 17110
 
MATCHING GIFT
Many employers will match your gift. This match can double and sometimes triple your support of the Foundation. Check with your human resources office and if a match is available, please send the matching gift form to PAFP Foundation at the address noted above.
Employer Name:
Job Title:
 
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The Foundation is a 501(c)(3) nonprofit organization registered with the Internal Revenue Service. A copy of the official registration and financial information may be obtained from the PA Department of State by calling toll-free within Pennsylvania 1-800-732-0999. Registration does not imply endorsement.

© Copyright 2011-2016, Pennsylvania Academy of Family Physicians and Foundation. All rights are reserved.
2704 Commerce Drive, Harrisburg, PA 17110
Toll Free: (800) 648-5623 Phone: (717) 564-5365 Fax: (717) 564-4235

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