VSA Resident/Fellow Donations

CONTRIBUTOR

First Name:
Last Name:
Degree:	MD PhD Other (specify)
Check this box if you are a current VSA member:

CONTACT INFORMATION

Billing Address:
City:
State/Province: (if applicable)
Zip/Postal Code:
Country: (leave blank if USA)
Email Address:

AMOUNT PLEDGED

	$500.00
	$250.00
	$200.00
	$150.00
	$100.00
	$50.00
	$25.00
	Other: $
PAYMENT INSTALLMENTS

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

PAYMENT

	Paying by check, 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 - your card will be charged for the remainder of your pledge according to the payment schedule selected)

CREDIT CARD INFORMATION

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:
Address associated with card:
ZIP Code: