1-Donor Name: __________________________ Business/Individual (if different from above): Address: Phone: Email: Fax:

Date: _________________

2-Involvement in C10: __Board __Advisory Board __Alumni __Grantee __Initiative Partner __Other: 3- Alumni Dues Structure: ___ A. Individual Membership: $50 (or higher) ___ B. Agency Membership: Annual dues, based on Agency Budget. Indicate level of support. $ Less than $50,000 = $125 $51,000 - $100,000 = $150 $101,000 - $250,000 = $200

$251,000 - $500,000 = $250 $501,000 - $1 million = $350 $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-Timeliness of Sponsorship: __Monthly Contribution __Annual Contribution Payment date: ____/_____/____ 6-Memorial Fund: "Growing The Legacy - In Rememberance" __Micheal L. Holdway __Michael Timmons __Helen Crowell __Genie Rumbelow 7-Method of Payment - Check One: __*Credit/Debit Card __**Bank Draft __ Check enclosed __Purchase Order # ___

One Time Gift

*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: __5
th

or __20

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Please Attach a Copy of a Canceled Check. 7-Printed Name of Authorizing Signature: 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 Date__________