Charitable Donation Form

To submit a donation by mail, print this page, complete your details and preferred charitable level, then mail the form and your check to The Pilcrow Foundation, 343 E. Washington Avenue, Cottage Grove, OR 97424

Title: _________ Name: _____________________________________________________

Street/P.O. Box: ___________________________________________________________

City, State, Zip: ___________________________________________________________

Email: ___________________________________________________________________

To support the work of The Pilcrow Foundation select your preferred method of giving:

___ I enclose my contribution of:

___$10  ___ $25 ___$50 ___$100 ___$150 ___$200 ___$250 ___$300 ___Other $ _______

___ I would like to be a Named Sponsor of The Pilcrow Foundation. Select the number of libraries you would like to support:

___$800 (1 library)  ___$1,600 (2 libraries)  ___$2,400 (3 libraries)  ___Other $ ______

As a Named Sponsor, I would like the following name(s) inscribed on the bookplates:

___In Honor of       ___In Memory of    ___To Celebrate     ___Name Only


Please use my contribution in the following state(s) _______________-OR- ___Where Needed