Giving Form - Brock Institute

* Denotes required field

Gift Amount & Designation:

EVMS Fund

EVMS Fund is an unrestricted fund that gives the school flexibility to pursue new programs and initiatives.

$

Amount

Designated Fund

Donors may designate or “restrict” the use of their donation to a particular purpose or project.

Area of Impact:

Select an area for your gift to make an impact

$

Amount

Donation Total $

US Currency

It is the policy of the EVMS Foundation that five percent (5%) of the total gift amount of a restricted gift made to benefit EVMS will be allocated to the unrestricted EVMS Fund. Beginning with any restricted gift made on or after July 1, 2012, EVMSF will allocate five percent (5%) of the total gift of each restricted gift to the EVMS Fund. Review the policy.

Additional Gift Information:

Make this gift:

In Memory of In Honor of

Prefix (optional)

First Name

Initial (optional)

Last Name

Please send tribute card to:

Tribute Card Name

First Name

Last Name

Tribute Card Address

Address Line 1

Address Line 2

City

State

ZIP Code

Donor Information:

Name*

Prefix

First Name

Initial

Last Name

Company

Address and Contact Information:

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone Number*

Home Business Cell

Email Address*

Home Business

EVMS Affiliation

Alumni Current Student Faculty/Staff Parent/Grandparent Resident/ Fellow Friend of EVMS

Would you like to receive updates from the EVMS Foundation?

Yes No

Payment Information:

Donation Total $

US Currency

Credit Card*

*I authorize the funds to be charged electronically, and I have read and agree with the refund policy below.

Refund Policy: Charitable gifts are generally not refundable. Refunds will be made in the event of a mistake or if the purpose for which the gift was given cannot be fulfilled by the Foundation. Individuals who receive refunds have the responsibility of correcting any tax filings they have made reflecting the refunded amount.

Additional Comments