Giving FormRegistration Information Title: ________________________ First Name: _____________________ Last Name *: __________________________________________ Address *: ___________________________________________________________ City *: _________________________________________________ State *: ______________________ Zip *: ________________________ Country * : _______________________________________ Phone: ___________________________________________ Email *: ___________________________________________ ______ I prefer to make my donation anonymously. Donation Information
Amount* _____________________________ Designation __ Annual Fund supporting all programs __ Scholarships __ Year-in-Israel Program for first-year students __ Jerusalem School __ Faculty Research __ Libraries __ American Jewish Archives __ Museums
Payment Information Credit Card Number* _______________________ Type/Expiration Date* ______________________(mm/yyyy) __ MasterCard __ Visa __ American Express __ Discover __ Diner's Club Cardholder's Name* ________________________ Card Security Code* ________________________
This gift is in honor of memory of someone special: In honor of ________________________________ or In Memory of ___________________________
Mail a letter of my behalf to the following person: Full Name _______________________________ Address _________________________________ ________________________________________ City, State, Zip ___________________________ Country _________________________________ Phone ___________________________________ E-mail ___________________________________ Please tell us how you heard about our site: __ HUC-JIR Chronicle Magazine __ HUC-JIR Annual Report __ Dean's newsletter __ Appeal letter __ Year-in-Israel appeal letter __ Mail insert __ HUCNews e-mail __ HUC-JIR Website __ HUC-JIR Event __ Referred by a friend __ Other *Denotes Required Information Please fax or mail this form to Ms. Diane Bongard |