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:
____-________
(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)
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.