UPPER IOWA UNIVERSITY DONOR CARD

Date ___________________

Name ______________________________________________________________
            (Please Print)

Class of ________

Address:          ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Home Phone: (      )_________________________ E-Mail Address:   ___________________________

Enclosed is my/our gift and/or pledge of $____________________ for

_____Annual Fund    _____ Communications and              Technology Fund

_____ Andres Center for Business           and Education _____Scholarship Fund

_____Library Challenge          Grant  _____    ___________

   _____Centers __________________(name of Center)

I / We would prefer to make payments over a period of 3 or 5 years (please circle one) in this manner:

_____Monthly     ______Quarterly      _____Semiannually       ______Annually

TOTAL PLEDGE_____________ Beginning on or about ________________, 20____

AMOUNT ENCLOSED____________ (make checks payable to Upper Iowa University)

If paying by credit card, please provide this information: _____ MASTERCARD _____ VISA Card Number ______________________ Expiration Date ____________________ Signature ________________________

Mail this form to: Upper Iowa University University Advancement PO Box 1857 Fayette, IA 52142 1-563-425-5388 alumni@uiu.edu

Your gift is tax deductible to the extent allowed by law.