Blessed to Build Campaign Pledge Card

Name Name First Last
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Total Amount of My Pledge
To be paid
Over this length of time

Over this length of time One Time 12 months 24 months 36 months 48 months 60 months 72 months
I will make my payments
Starting on this date Starting on this date / MM / DD YYYY
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
For Office Use
Received ___/___/____ By ________ PDS ____/____/____ Ack ____/____/____