Mayatan Assistance Program Pledge Form

Thank you for pledging your support of Mayatan Foundation

Step 1: My Pledge Information

Amount

I would like to pledge
	$50
	$100
	$250
	$500
	$1,000
	$2,500
	Other | $ (please indicate the amount)

Installments

I would like to make my pledge in:
	1 single payment
	12 monthly installments
	Other: (please indicate how many installments you would like to make)

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Step 2: My Contact Information

Name:

-- Dr. Mr. Mr. & Mrs. Mrs. Ms.
Title	First	MI	Last

Mailing Address: E-mail Address:

e-mail address

please re-enter your e-mail address to ensure accuracy

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Step 3: Other Information

Please add me to the Newsletter mailing list

Yes

No

It is okay to thank me publicly for my pledge

Yes

No

Please contact me about other opportunities to invest in Mayatan Foundation

Yes

No

Comments

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