American College of Osteopathic Pediatricians (ACOP)

Caring for America's Children

Pediatric Research & Education for Students (PRES) Fund Pledge and Donation Form

American College of Osteopathic Pediatricians
Pediatric Research & Education for Students (PRES) Fund

ACOP is a 501(c)6 organization. Donations to the PRES Fund may be tax deductible as allowed by law. Tax ID # 23-7111697

 

CONTRIBUTOR
   
First Name: 
Last Name: 
Degree: 
DO PhD
Other (specify)
Check this box if you are a current ACOP member: 
   
CONTACT INFORMATION
   
Billing Address: 
City: 
State: 
Zip: 
Email Address: 
   
DONTATION/PLEDGE
 
In memory of: (optional) 
In honor of: (optional) 
   
$5,000
$2,500
$1,000
$500
$250
$100
$50
Other: $
Annual payments over year(s)
One-time payment
   
PAYMENT
 
Please invoice me for payment (available for donations/pledges of $1,000 or more)
I wish to make the full payment now (Please fill out credit card information below)
I wish to make a partial payment now (available for donations/pledges of $1,000 or more): $
(Please fill out credit card information below - you will be invoiced for the remainder according to the payment schedule selected)
   
CREDIT CARD INFORMATION
   
The following is ONLY required if choosing to make a payment now.
Credit Card Type: 
VISA MasterCard AMEX Discover
Card Number: 
Security code: 
For VISA or MasterCard it is on the back of your card in the signature box. The 3-digit code is printed on the right-hand side of your 16-digit credit card number.
For American Express the code is the 4-digit number printed on the front of your card either on the right-hand side directly above the credit card number or the left-hand side directly above the credit card number.
Expiration Date: 
Card Holder Name: