2018 Panther Club Donation Pledge Form
(July ‘17-June ‘18)
Y ES, I’D LIKE TO JOIN THE PANTHER CLUB YES, I’D LIKE TO RENEW MY MEMBERSHIP
CUSTOMER INFORMATION
Please mail completed form to: University of Pittsburgh, Department of Athletics-Panther Club DONOR NAME: ACCOUNT #: p.o. box 7436 Pittsburgh, pa 15213 STREET ADDRESS: if you have questions regarding your account please contact the CITY: STATE: ZIP CODE: panther club at
[email protected] or call (412) 648-8889 PHONE NUMBER:
2018 PITT PANTHER CLUB MEMBERSHIP GIVING LEVELS P ANTHER CLUB CONTRIBUTOR PANTHER VICTORY BLUE GOLD DIRECTOR CHAMPION SUTHERLAND SOCIETY ACC EXCELLENCE CIRCLE
PAYMENT SCHEDULE $1 - $99 $100 - $299 $300 - $749 $750 - $1,499 $1,500 - $2,999 $3,000 - $5,999 $6,000 - $11,999 $12,000 - $17,689 $17,690+
I would like to give a gift in the amount of $ to help provide the scholarship resources necessary to support 475 Pitt student-athletes in 19 varsity sports.
HAIL TO PITT!
PAYMENT METHOD PAY IN FULL Check: Made payable to University of Pittsburgh. Charge Card for Selected Months:
(cards will be charged on the 1st of every month selected)
JULY ‘17 AUGUST ‘17 SEPTEMBER ‘17 OCTOBER ‘17 NOVEMBER ‘17 DECEMBER ‘17 JANUARY ‘18 FEBRUARY ‘18 MARCH ‘18 APRIL ‘18 MAY ‘18 JUNE ‘18
$ $ $ $ $ $ $ $ $ $ $ $
PAYMENT VERIFICATION AUTHORIZATION NOTE: I authorize and acknowledge that all of the charges above will be processed to my payment card as noted below. (The card provided must be in the name of the account holder. If using a debit card, please be advised that this authorization may affect your checking account until final settlement of the transaction.) Payment Card Industry regulations prohibit merchants from requiring or making copies of your credit / debit cards.
A merican express *Cardholder’s Full Name:
*CREDIT / DEBIT CARD NUMBER:
discover
mastercard
v isa *Cardholder’s Signature:
*EXPIRATION DATE:
*CVV: *REQUIRED FIELDS