SIU School of Medicine Foundation

Please complete, click the "print" button and mail the form to:
SIU Foundation
P.O. Box 19666
Springfield, IL 62794-9666

I/we would like to support

by giving $
through the SIU Foundation.
I wish to make a second gift to another area:

by giving $
through the SIU Foundation.
I wish to give to the department not listed above: by giving $ through the SIU Foundation.  
 
Date
 
Donor(s) Name
(Please type in name as it should appear in the Annual Honor Roll of Donors)
Do not include my name in the Honor Roll
 
Home Address 1
 
Home Address 2
 
City    State    Zip   
 
Home Phone Number    E-mail   
 
Has Your Address Changed Recently ? Yes   No

 

Joint Gift Yes   No    
  Spouse Name
    First Name Middle Name Last Name
  Payment can be in the form of:
 
Check payable to "SIU Foundation"
 
Credit Card:
 
Visa Discover Master Card
  Credit Card #   Exp.Date  3 digit CVV2 code What is a CVV2 code?
 
Signature of Donor  ____________________________________
 
 

Do you work for a matching gift company? Yes No
Does your spouse work for a matching gift company? Yes No
(If yes, please enclose your company's matching gift form and/or notify your personnel department.)

Thank you for your support !