Please print, fill out and fax or mail this form. Checks should be made payable to Preservation North Carolina. |
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Preservation North Carolina
220 Fayetteville Street, Suite 200
P.O. Box 27644
Raleigh, NC 27611-7644
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Office: 919-832-3652
Fax: 919-832-1651
EMail:
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Donor Information
Full Name:______________________________________________
Address: _______________________________________________
City/State/Zip: ___________________________________________
Daytime phone: _______________________ Fax: _______________________
Email: _______________________________
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__ $5,000 & up
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Professional Sponsor
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__ $1,000–$2,500
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Professional Friend
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__ $ 500
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Preservation Professional
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__ $ 150
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Individual Practitioner
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Amount Enclosed
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Method of Payment
___Check ___Visa ___ MasterCard ___American Express ___Discover
Cardholder name: __________________________________
Credit card account number: _______________________ Expiration date: ___________
Signature: ______________________________________ Phone#__________________
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