Mail-In Donation

Mail-In Donation Form

(Fill out this form, print the form, and mail to)

Lubeznik Center for the Arts

101 W. 2nd St

Michigan City, IN 46360

I/We are pleased to contribute the sum of $ to benefit the Lubeznik Center for the Arts.

My/Our gift is to be used for the following purpose:

To be used for the general purpose of the campaign.

Payment Information:

Check amount enclosed: $ Check #

I/We wish to make my/our pledge payment by credit card.

Please check one: Visa MasterCard Card No.

Print name as it appears on card Exp. Date: Month/Year

Signature(s) ________________________________ Date ___________

________________________________ Date ___________

I/We expect to make this gift over a period of years as stated below:

Month/Year

Amount $ $ $

Name(s) as you wish listed for recognition purposes (Please print)

Name(s)

Home address

City State Zip Code

Home Telephone e-mail

My Company will match my contribution.

Company

Contact Name Phone

I/We prefer that our gift remain anonymous.

The Jack and Shirley Lubeznik Center for the Arts is a non profit organization. Contributions are tax deductible to the full extent of the law.