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 1 2 3 4 5 year(s) Bi-annual payments over 1 2 3 4 5 year(s) Quarterly payments over 1 2 3 4 5 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: 1 2 3 4 5 6 7 8 9 10 11 12 Month 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 Year Card Holder Name: Address associated with card: ZIP Code: