Pledge Form

Bologna Center Contribution/Pledge Form
Fred Hood Research Fund, Class of 2002
(Please fill out and return to the Bologna Center Office of Development by Fax.+39/051.228505 or email to gchiappini@johnshopkins.it)

_____________________________________________

Name (Surname)                                               (Name)                                                    (Maiden Name)

Address
(Street)                                                                      (City)                                             (Postal/Zip Code)

Country                                                            Email

………………………………………………………………………………………………

Organization                                                                             Job Title

Address

(Street)                                                                      (City)                                             (Postal/Zip Code)

Country                                                            Email

……………………….………………………………………………

My gift is for: The Fred Hood Research Fund

THE SCHEDULE

I/we will make a total gift of $/€__________.
There will be  ________ (number of) payments over _________ (number of) years starting on ______________________ (date) in (choose one below):

___  one single payment

___ equal payments

OR

___ a 1st payment of __________, 2nd payment of___________, 3rd payment of__________, 4th payment of___________, 5th payment of__________.

THE METHOD

I will make my payment(s) by way of (please mark one):

____ check made payable to the Johns Hopkins SAIS Bologna Center

____ appreciated securities

____ credit card

• Card type:      ___ Visa      ___  Mastercard     ___  American Express

• Card number __________________________________

• Exp. Date:____/____

• Name on card____________________________________

• Validation No. _________

* Validation number is a 3-digit number printed on the back of your Visa or Mastercard. For American Express, it is a 4-digit number printed on the front right side

___  Other (by way of another entity such as the Associazione Italo-Americana, UK Foundation, Verein der Freunde des Bologna Center, King Badouin Foundation, Fondation de France, Stichting Johns Hopkins University-Bologna Center- in which case please follow the attached giving instructions)

___  My company will match my gift.

Company name________________________________________

Signed:  __________________________________________________

Date: _________________