Name:
Address:
City: State: Zip:
Phone: Fax:
Email:

Donation amount:

$50
$75
$100
$250
$500
$1000 and over - Land Legacy Society
Other contribution ____________

Contribution method:

Enclosed is a check made payable to Gathering Waters Conservancy.

--or--

Please charge my: Visa Master Card

card #________________________________________________   exp. date___________

signature __________________________________________________________________

I would like to make a one-time contribution using my credit card.
I would like to make a recurring monthly contribution using my credit card.
       Please charge my card $_______ on the 1st or 15th of each month.

Donations are tax deductible as allowed by law.
Financial statements are available upon request.

Send form and contribution to:

Gathering Waters Conservancy
211 S. Paterson St., Suite 270
Madison, WI 53703
Fax: 608-663-5971