Piedmont Wildlife Center Donation Form

People who donate $35 are considered members of Piedmont Wildlife Center as long as they meet all other membership criteria specified by our bylaws.
I am joining at the following level:
$35____Member
$100____Supporting Member
$250____Contributing Member
$500____Wildlife Partner
$1000____Conservationist's Circle
$2500____Wildlife Advocate's Circle
$5000____Director's Circle
$____ ____Other
If this is in honor of, in memory of, or is a donation towards a naming opportunity, please give information below. If you would like the honoree to be notified of your gift, please provide their address as well. All donations are considered nonrestricted.
 

O I am paying by check, which is enclosed, made out to Piedmont Wildlife Center.
O I am paying by Visa, MasterCard, or Discover.

Contact Address:

Name:__________________________________________________________________
Address:_______________________________________________________________
City: ____________________________ State_______ Zip:___________________
Phone(s)/email:________________________________________________________
My company ___________________________ matches charitable contributions.

For Credit Card Donations:

If your credit card billing address or name is different than above, please provide it here.

Name as shown on Card::__________________________________________________
Address:_________________________________________________________________
City: ____________________________ State_______ Zip:_____________________
Credit Card (please circle): Visa / MasterCard / Discover

Number:_________________________________________ Expiration Date:____/____

O I am already a member.
O Please do not publish my name in the Center's newsletter.

Fax (919 493-0988) or mail this completed form to:
Piedmont Wildlife Center
Administrative Office
364 Leigh Farm Road
Durham, NC 27707