Capital Campaign Pledge Form

Capital Campaign Pledge Form

to Support the Piedmont Atlanta Tower Campaign

Click to type directly within form or print to complete
Donor(s): ______
Address: ______
City, State, Zip: ______
Home Phone: ______Business Phone: ______
Cell Phone: ______
Email:______
Total Pledge Amount:
$ ______
Method and Terms of Payment:
☐I am paying my pledge in full today.
☐Check enclosed and payable to Piedmont HealthcareFoundation
☐Credit card gift made online at
(For your security, please do NOT include credit card information on this form.)
☐I will make a single future payment on (date) ______.
☐I would like to make multi-year payments beginning on
______(date) over the next ______years (5 years max)
☐Please bill me.
☐I would like to provide a credit card for auto-pay.
(For your security, please do NOT provide credit card information on this form.)
☐Payroll Deduction (Employees Only)
Please begin bi-weekly deductions of $______beginning on
______(date) over the next ______pay periods
☐Planned Gifts and Stock:please call 404.605.2130
☐Other (please specify):
______
☐My gift will be matched by:
______
☐Matching gift enclosed
☐Matching gift form to follow
/ Donor Recognition
Does the Piedmont Healthcare Foundation have your permission to publicly acknowledge your commitment?
☐Yes
☐No
.
How would you like your name listed?
______
Honor/Memorial/Tribute
This gift is made in honor/memory of:
______
Please send notification of my honorary/memorial gift to:
Name: ______
Address: ______
City, State, Zip: ______
Special Instructions:
______
Employees Only
Employee ID: ______
Role at Piedmont:
☐Physician
☐Other (Please Specify):
______
This pledge form serves as a confirmation of my commitment to make a financial gift towards the
Piedmont AtlantaBuilding Better Capital Campaign.
Donor Signature:
______
Date: ______
The Piedmont Healthcare Foundation’s Federal Tax Identification Number is58-1272768. Donations are
tax-deductible to the extent provided by law.

Please email your form to Questions? Call: 404.605.2130

ormail to: Piedmont Healthcare Foundation For More Information:

2001 Peachtree Road, N.E • Suite 400 • Atlanta, Georgia 30309