In support of the Dr. Edward D. Kozlowski Science Learning
Laboratory, Kopernik Space
Education Center, and Roberson Museum and Science Center, the following is pledged:
A total of $__________________________ to be paid by _______________________Date
|Payments will be made:||______||Annually|
|______||Other (Please Specify)|
Please charge my credit card for the following amount: $______________________________
Card # ________-________-________-________ Expiration Date:
(VISA, DISCOVER, MASTERCARD)
Name as it appears on the card: __________________________________________________
______ My (my spouse’s) company will match this gift.
Company Name: ____________________________________________________________
______ I / We prefer to have this gift be anonymous
This pledge should be acknowledged and recorded as a gift from:
(Please indicate how you would like your name to appear in print)
City: ________________________ State: ______________ Zip Code: ______________
|Telephone: (Day) (______) ______ - ________|
|(Evening) (______) ______ - ________|
Signature: _______________________________________Date: _________________
Please make checks payable to: Roberson/Kopernik Dr. Ed project.
Please mail this form and payment(s) to Roberson/Kopernik Project, 30 Front Street, Binghamton, New York 13905.
Should you have any immediate questions, please contact Kristen Kozlowski Gordon at 607-772-0660, ext. 208.