Diverse and Resilient - Printable
Donation Form
Print this form out, fill it in, and fax it to us (if paying by credit
card) or send it in the mail (if paying by credit card, cash, check, or money
order), but please do not send your information to us via email because it is
not secure. If you have any questions please call us at 414-390-0444 or email
us at director@diverseandresilient.org. Please remember to sign any checks
or money orders and make them payable to:
Diverse and Resilient
2439 N Holton St
Milwaukee, WI 53212
414-390-9980 Fax
We appreciate each and every gift we get…from the three $5.00 bills stuffed
into the envelope with a brief note to the $15,000 gift that allows us to develop
new programming to reach more people. Each one counts; each one matters. Below
you can select a gift level from the menu or decide for yourself. If this gift
is in honor of a loved one or friend, let us know that: be sure to list the honoree's
name. You will receive a letter of acknowledgement in 10 days with our deepest
thanks on behalf of all the people your gift will touch. And
remember, your generosity to Diverse and Resilient is tax deductible!
Donation Amount - Circle the amount you want to donate or enter the amount
on the line below
$35 $50 $100 $250 $500 $1,000 Other (specify
below)
(Other) ____________________________________________
Designate Your Gift (optional) Circle an option...
" I would like to give this as a General Donation
" I would like to give this to support youth programs
" I would like to give this to support adult programs
" I would like to give this for Milwaukee area efforts
" I would like to give this for transgender health initiatives
" I would like to give this for bisexual women and men's health initiatives
" I would like to give this for lesbian health initiatives
" I would like to give this for gay men's health initiatives
" I would like to give this as an Honorary Gift (name below).
" I would like to give this as a Memorial Gift (name below).
(Name of Honoree) ____________________________________________
Donor Information
- Enter your information here.
First Name ____________________________________________
Last Name ____________________________________________
Address ____________________________________________
City ____________________________________________
State - Circle a State: AK AL AR AZ CA
CO CT DC DE FL GA HI IA ID IL
IN KS KY LA MA MD ME MI MN MO
MS MT NC ND NE NH NJ NM
NV NY OH OK OR PA RI SC SD
TN TX UT VA VT WA WI WV WY
Zip ____________________________________________
Phone ____________________________________________
Fax ____________________________________________
Email Address ____________________________________________
Honoree Information
(optional) - If this gift is an honor/memorial, please be sure to include
the address where the acknowledgement should be sent in the space provided below.
This address could be to the honoree or the honoree's family.
Who the acknowledgement is being sent to if it is not being sent to the honoree
(optional)
____________________________________________
Address ____________________________________________
City ____________________________________________
State - Circle a State: AK AL AR AZ CA
CO CT DC DE FL GA HI IA ID IL
IN KS KY LA MA MD ME MI MN MO
MS MT NC ND NE NH NJ NM
NV NY OH OK OR PA RI SC SD
TN TX UT VA VT WA WI WV WY
Zip ____________________________________________
Please enter your credit card information below (optional):
Card Type - Circle a Card:
Visa Mastercard
Name On Card ____________________________________________
Credit Card Billing Address ____________________________________________
Credit Card Billing ZIP ____________________________________________
Credit Card # ____________________________________________
Card Expiration Month - Circle a Month:
January February March April May June July
August September October November December
Card Expiration Year - Circle a Year:
2003 2004 2005 2006 2007 2008 2009 2010
2011 2012
Signature - By signing
on the line below, I authorize Diverse and Resilient to charge the donation
amount specified to my credit card account:
____________________________________________
Diverse and Resilient
2439 N Holton St
Milwaukee, WI 53212
414-390-9980 Fax
Thank you for your donation!