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I (we) want to support Piedmont CASA with a gift of:

Dollar Amount: .00

Name (as it appears on your card):
Address 1:
Address 2:
City:  State:    Zip: 
Phone with area code: Will be used only if there is a question about this gift
Email Address:
Our Contributor categories are:
Pacesetter: $5,000+
Ambassador: $2,500-$4,999
Benefactor: $1,000-$2,499
    Patron: $500-$999
Friend: $100-$499
Donor: $1-$99

Credit Card type:
Credit card number:
Expiration date:    
 mm         yyyy
Card name and address
if different than above:
Name(s) as you wish it published:
  I prefer not to have my name published
In Memory of:
In Honor of:
Matching Gift / Employer Name:

No goods or services were exchanged for this charitable donation, which is tax deductible for Federal income tax purposes. A financial statement is available upon written request from the Virginia Department of Agriculture, Office of Consumer Affairs.

Piedmont CASA, 818 East High Street, Charlottesville, VA 22902     434.971.7515     Fax: 434.971.3060

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