1-Donor Name:
__________________________      Date: _________________

Business/Individual (if different from above):                                                               

Address:
                                                                                                                                 

Phone:                                                   Fax:                                                

Email:                                                                                                           

2-Involvement in C10:   __Board   __Advisory Board   __Alumni  

 __Grantee   __Initiative Partner   __Other:                                        

3- Alumni Dues Structure: what is a member? 
 
___ A. Individual Membership:   $50 (or higher)
  ___ B. Agency Membership:  Annual dues, based on Agency Budget.

Indicate level of support. $                             
Less than $50,000 = $125                                  $251,000 – $500,000 = $250
$51,000 – $100,000 = $150                               $501,000 – $1 million  = $350
$101,000 – $250,000 = $200                             $1 million or more = $450                           

4-Pledged Gift &/or “Pay it Forward” Level of Support  $                           
Full Circle ($10,000 and over) 20+ Leaders                      Patron ($500 – $999) 1-2 Leaders
Sustainer ($5,000-$9,999) 10-19 Leaders                        Supporter ($100 – $499)
Benefactor ($1,000-$4,999) 3-9 Leaders                          Friend ($50 – $99)

5-Memorial Fund: “Growing The Legacy – In Remembrance”
__Micheal L. Holdway    __Michael Timmons
__Helen Crowell              __Genie Rumbelow 

Relationship:  __Spouse    __Father    __Mother    __Siblings   __Child
                              __Friend    __Neighbor    __Co-Worker    __Other

6-Timeliness of Sponsorship:
__Monthly Contribution   __Annual Contribution        One Time Gift       

Payment date:  ____/_____/____

 7-Method of Payment –  Check One:
__*Credit/Debit Card __**Bank Draft __ Check enclosed   __Purchase Order # ___     _ 

*For Credit Card: Send by mail/fax OR Circle of Ten staff will complete credit transaction details by phone.

Credit Card Account #  __ __ __ __–__ __ __ __–__ __ __ __–__ __ __ __

Type:  __Visa   ___MasterCard   __AmEx    Expiration date:  ____/_____

Name as it appears on credit card                                                              

**For Monthly Bank Draft:  Complete the Debit Authorization Form Below:
I (we) hereby authorize A Circle of Ten, Inc.-Network for Collaboration  to initiate a charge to my (our) checking/savings account at the Financial Institution indicated below, and if necessary initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until The Company is notified by me (us) in writing to cancel it in such time as to afford The Company and Financial Institution a reasonable opportunity to act on it.

_________________________________           __________________________
Name of Financial Institution                                          Location (City, State)

Financial Institution’s Routing Transit Number:  __ __ __ __ __ __ __ __ __

__Checking Account   OR   __Savings Account #_____________________ 

Monthly Draft Amount: $                       Draft Date:  __5th   or   __20th                     

Please Attach a Copy of a Canceled Check.

7-Printed Name of Authorizing Signature:                                             Date__________

8-Authorizing Signature:                                            

To Return Pledge Form
By Mail:  A Circle of Ten, Inc.  205 E. Commerce, 205  Jacksonville,  TX  75766
By Fax:  888-214-5210
By Email:  circleof10@circleof10.org