Bernie Lorenz Pledge Form

Home
Services
Success Stories
Donation
Pledge Form

Thank you in advance for your pledge
Please fill out the following information so that we can thank you appropriately! You may print out this form and mail it to:

Bernie Lorenz Recovery
4014 Kingman Blvd.
Des Moines, IA 50311

I/We would like to make an investment in the future of Bernie Lorenz Recovery in the amount of:

$25
$50
$75
$100
$250
$500
Other	Amount:

Name


Address

City		State		Zip/Postal Code


E-mail:		Home Phone:


Work Phone:		Fax Number:


	Check is enclosed
	Please bill me/us
	Monthly Quarterly Semi Annually Annually
	Please contact me/us about a stock transfer (please be sure to list daytime phone number above)
	I would like this gift to be anonymous
	My company matches donation amounts *
	I/We would like to include Bernie Lorenz Recovery in my/our will, please send information.

* NOTE: If your company matches your contributions, please request a form from your company and include with your donation.

Since Bernie Lorenz is a non-profit corporation your contribution may be tax deductible per IRS regulations.

Please print this form for your records using the print button on your browsers toolbar.
Upon receipt of your donation you will receive acknowledgement of your gift.