Orthodontic Staff Pledge Form
Please complete, sign and fax to the AAOF at 314-993-5208

YES, COUNT ME IN!  I want to support the AAO Foundation's mission to "Advance the orthodontic specialty by supporting orthodontic education and research."

Please select one of the two following options:

[ ] I would like to make a one-time gift of $__________

[ ] I would like to contribute $________ quarterly for a period of ___ years.

In either event, please bill my creditcard as follows: 

Cardholder Name: __________________________________________

[ ] Visa  [ ] MC  [ ] AmEx   Account Number: ________________ Exp. Date _____

VBA Number: ________ (The VBA number is a three digit number on the back near the signature)

Billing Address ____________________________________________________

City: ______________ State: _________ Zip: __________

PLEASE MAKE ONE OF THE FOLLOWING TWO DESIGNATINS:

[ ]     Please use my donations to further the Foundation's mission to 
        support orthodontic education and research at the discretion of 
        the Board of Directors.

[ ]     Please restrict my gift to the Foundation's Endowment using only the 
        earnings from my gift to advance the mission of the Foundation.

 

Signature: ________________________________   Date:____________

 

COMMENTS __________________________________________________

____________________________________________________________

____________________________________________________________

 

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Doctor's Name ________________________________________________

Telephone ____________________ Fax ___________________________

Doctor's Email ________________________________________________

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