Donor or Donors:
(as you wish to be listed publicly)

Check here if you wish to remain anonymous:

Address:

City:

State:

Zip:

Daytime Phone Number:

Evening Phone Number:

Email Address:

I/we wish to contribute to the Clinical Nurse Specialist Foundation. My total gift, payable over five years, will be:

$5,000: $3,000: $2,500: $1,000: $600: $500: $250: $100:

Other:

I/we understand that all gifts are tax deductible to the extent allowed by law. The Clinical Nurse Specialist Foundation is registerd as a charitable organization under IRC 502(c)(3) (tax ID# Please send all contributions to: The Clinical Nurse Specialist Foundation, 2090 Linglestown Road, Suite 107, Harrisburg, PA 17110.

I prefer to make payment(s), beginning (month/year) over a period of (1-5) years, on the following schedule:

Monthly: Quarterly: Semi Annually: Annually:

My first check is enclosed, made payable to The Clinical Nurse Specialist Foundation

Please charge my credit card automatically for each payment (complete information below).

Credit Card Information:

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Expiration Date (month/year):

The official registration and financial information of The Clinical Nurse Specialist Foundation may be obtained from the Pennsylvania Department of State by calling toll-free, within Pennsylvania, 1-800-732-0999. Registration does not imply endorsement.