Patient Safety Education & Research Fund Pledge and Donation Form

SPA is a 501(c)3 organization, and contributions are tax deductible.

CONTRIBUTOR

First Name:

Last Name:

Degree:

MD PhD
Other (specify)

Check this box if you are a current SPA member:

CONTACT INFORMATION

Billing Address:

City:

State:

Zip:

Email Address:

PLEDGE

In memory of: (optional)

In honor of: (optional)

The suggested pledge is $5,000 over any timeframe up to 5 years.

	$5000.00
	$2500.00
	$1000.00
	$500.00
	$250.00
	$100.00
	$50.00
	Other: $

	Annual payments over year(s)
	Bi-annual payments over year(s)
	Quarterly payments over year(s)
	Monthly payments over year(s)
	One-time payment

PAYMENT

	Please invoice me for payment
	I wish to make the full payment now (Please fill out credit card information below)
	I wish to make a partial payment now: $ (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: