Print Form Multi-Year Pledge Form 5154 Email Form This form allows you to create a multi-year pledge to Purdue University and set up a schedule to receive reminder notices by mail. If you desire to set up automatic payments by credit card or debit card, select “Set Up Recurring Gifts” instead of this form. Gift Information: I/We pledge to give $_____________ (excluding any anticipated matching gifts). Designation (list dollar amount of each payment): $____________ The Fund for Purdue (018605) $____________ College/School (specify) _________________________ $____________ Department (specify) ____________________________ $____________ Other (specify):_________________________________ Purdue Foundation will mail pledge statements based on the schedule you determine is best for you. You will be able to pay by credit card or debit card. Frequency of payments (select one) ☐ Monthly ☐ Quarterly ☐ Semi-annually ☐ Annually Duration of payments (number of years) ________________ Start date____________________ Signature_________________________________________ Date________________________ Signature_________________________________________ Date________________________ Optional Payment Enclosed is the first payment of $__________________ Credit or Debit Card I authorize Purdue University to charge $____________ to my: ☐Visa ☐MasterCard ☐Discover ☐American Express Card Number:________________________ Exp. Date: ___/___ CVV:_______ Printed name as it appears on card:______________________________________ Billing Address: ____________________________________________________ ☐Same as mailing address (please supply below) Signature:____________________________________ Date:_______________ Matching Gifts ☐I anticipate that my gift will be matching by (specify company) _______________________________ Donor Information Name ______________________________________ Street Address _______________________________ City _______________________________________ State _______________ Zip Code ________ Telephone __________________________________ E-mail _____________________________________ Alumna/us? ☐Yes ☐No Year Graduated_______ Name at Graduation:___________________________ Spouse Information Spouse Name________________________________ E-mail______ _______________________________ Alumna/us? ☐Yes ☐No Year Graduated_______ School ______________________________________ Name at Graduation ___________________________ Mail form to: Purdue Foundation, 403 West Wood Street, West Lafayette, IN 47907-2007 Contact us at: (800) 319-2199 or [email protected] EA/EOU Produced by Purdue Marketing and Media 10.UDO.3.029a