Kopernik Polish Cultural Society
Dr. Edward D. Kozlowski Science Learning Laboratory

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
______ Quarterly
______ Other (Please Specify)

Please charge my credit card for the following amount: $______________________________

Card # ________-________-________-________  Expiration Date: ____-________

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)

Donor: _________________________________________________________________

Address: ________________________________________________________________

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.

Dr. Ed Kozlowski MemorialZpowrotem do Strony Glownej