Jeremy Burnett Scholarship Fund

Donation Form
Title:	Dr. Fr. Mr. Mrs. Ms. Rev.
First Name*
Last Name*
Organization
Address
Address 2
City
State	-- Select -- Out Of State AL Alabama AK Alaska AZ Arizona AR Arkansas CA California CO Colorado CT Connecticut DE Delaware DC District of Columbia FL Florida GA Georgia HI Hawaii ID Idaho IL Illinois IN Indiana IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine MD Maryland MA Massachusetts MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NE Nebraska NV Nevada NH New Hampshire NJ New Jersey NM New Mexico NY New York NC North Carolina ND North Dakota OH Ohio OK Oklahoma OR Oregon PA Pennsylvania RI Rhode Island SC South Carolina SD South Dakota TN Tennessee TX Texas UT Utah VT Vermont VA Virginia WA Washington WV West Virginia WI Wisconsin WY Wyoming
Country
Zip
Home Phone
Cell Phone
Fax
E-mail*
Amount of Donation* (Format for "other" amount does not include dollar signs, commas, or decimal point.)	$50.00 Givers Circle $100.00 Givers Circle $250.00 Friends Circle $500.00 Success Circle $1000.00 Dedication Circle $2500.00 Promise Circle $5000.00 HOPE Circle $10000.00 Generals Society $25000.00 Empowerment Society Other
I would like this donation to be used for	-- Any Available Progams -- Jeremy Burnett Scholarship Fund
Donation	One time donation I would like to make this a recurring monthly donation
Privacy	Provide my name and e-mail address to the charity I prefer to make this contribution anonymously
Designation (optional)	To designate your donation for a specific purpose, please enter a description of how you'd like your donation to be used.
Dedication (optional)	To make a donation in memory of another person, please enter the person's name To make a donation in honor of another person, please enter the person's name
Questions/Comments
	Enter in the Code exactly as you see it before clicking the 'Submit' button.
*Indicates required field