Credit Card Authorization Form

National Brokerage Agencies and Foundation Board Vice President Robin Landers are committed to improving the lives of those in need in our local communities by contributing to the NAILBA Charitable Foundation’s 2017 fundraising campaign. NBA will match member contributions up to $2,500, and Robin will match contributions over that up to $1,000, bringing the total amount eligible to be matched to $3,500. Our $3,500 plus your $3,500 = a huge boost to the charities supported by grants from the NAILBA Charitable Foundation. Together we can raise at least $7,000 to celebrate the 15 year of Foundation giving!

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Contributions must be received at NAILBA by June 30 to be matched as part of this campaign. Count me in for _____ $250

_____ $500

_____ On my behalf

_____ $1,000

_____ Other: $__________

______ On behalf of my organization

_____ I prefer to be listed as anonymous Donor Name:

_________________________________________________

Organization:

_________________________________________________

Address:

_________________________________________________ _________________________________________________

Phone:

_________________________________________________

Email:

_________________________________________________

Date:

_________________________________________________

Please make your check payable to the NAILBA Charitable Foundation. To make a donation with your credit card, please complete and return this form to the address below:

Credit Card Authorization Form Credit Card Type: Credit Card Number: Expiration Date:

_____ Visa

_____ MasterCard

_____ American Express

_________________________________________________ ________

Cardholder Name:

_________________________________________________

Billing Address:

_________________________________________________

City, State Zip:

_________________________________________________

Amount to Be Charged:

_____$250

_____$500

_____$1,000

_____ Other: $________

Authorized Signature of Cardholder: _________________________________________________ This form is a record of payment only. An official receipt will be forwarded when payment is processed. Donations to the NAILBA Charitable Foundation are tax deductible. Tax ID # 56-2448850.

NAILBA Charitable Foundation | 11325 Random Hills Road, Suite 110 | Fairfax, VA 22030 | www.nailbacharitablefoundation.org