Thank you for contributing to Future Leaders: The Capital Campaign for Harlem Academy. Your generosity will help to ensure a lasting pathway for generations of leaders to come. Thank you for supporting Harlem Academy! Donor Information Organization name: Name: Title: title Councilmember Mr. and Mrs. Officer Rev. The Rev. Mr. Ms. Mrs. Dr. Miss Master Prof. The Honorable Judge Rabbi Reverend Sister Father Brother Lt. Capt. Major Cmdr. Col. Admiral General Ambassador Senator Governor Sir Madam Sir/Madam Drs. The Reverend The Reverend Dr. Dr. and Mrs. The Rev'd. Judge & Mrs. Chef Canon e Special Agent First name: Last name: Email: Phone: Country: Algeria Australia Bahrain Canada Chile Colombia Egypt Ethiopia India Iraq Jordan Kuwait Lebanon Morocco New Zealand Oman Qatar Saudi Arabia Singapore South Africa Spain Tunisia United Kingdom United States Yemen Azerbaijan (Cyrillic) Ukraine Pakistan Uzbekistan (Cyrillic) Belarus Bulgaria Bangladesh Bosnia and Herzegovina (Cyrillic) Czech Republic Denmark Austria Liechtenstein Luxembourg Maldives Greece Belize Ireland Jamaica Malaysia Philippines Trinidad and Tobago Zimbabwe Argentina Bolivia Costa Rica Ecuador Guatemala Honduras Mexico Panama Peru Puerto Rico Paraguay El Salvador Uruguay Estonia Senegal Faroe Islands Belgium Cameroon Israel Haiti Mali Croatia Japan Turkey Turkmenistan Thailand Address: City: State & zip: State: state AA AB AE AK AL AP AR AS AZ BC CA CO CT CZ DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NL NH NJ NM NS NT NV NY OH OK ON OR PA PE PR PW QC RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT NU N/A Zip: City & county: City: County: county (optional) Leicestershire Postcode: City: Province & postal: Province: province AA AB AE AK AL AP AR AS AZ BC CA CO CT CZ DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NL NH NJ NM NS NT NV NY OH OK ON OR PA PE PR PW QC RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT NU N/A Postal: Suburb: State & postcode: State: state AA AB AE AK AL AP AR AS AZ BC CA CO CT CZ DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MH MI MN MO MP MS MT NB NC ND NE NL NH NJ NM NS NT NV NY OH OK ON OR PA PE PR PW QC RI SC SD SK TN TX UT VA VI VT WA WI WV WY YT NU N/A Postcode: Suburb: suburb City & post code: City: city Post code: I would like this gift to remain anonymous Extra Information Acknowledge me as Gift Matching? Yes No Employer Name Donation Gift amount: $25,000$15,000$10,000$5,000$2,500Other Amount: Designation Designation: Capital Campaign other Designation: Any special instructions for handling your gift? (e.g. in memory of, in honor of) Recurring Gift? Make this a monthly gift Give monthly on day 1 of each month Your first gift will occur on 11/1/2021 Payment details Payment Processed by Blackbaud Cardholder name: Card number: Card type: <Please Select> Visa American Express Discover MasterCard Expiration: Month: month 01 02 03 04 05 06 07 08 09 10 11 12 Year: year 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 CSC: Is the information you entered to set up the Direct Debit Instruction correct? Account holder: Sort Code: Account number: Amount to be debited: Collection frequency: Date of first gift:
