Pledge Information Collection QMC

Thank you for choosing to support Queen’s exciting plans for the Big Island. We are deeply grateful and honored to have you join in advancing healthcare on the Kona Coast. Please complete the form below to be contacted by Queen’s Philanthropy with a draft gift agreement.

Donor Name(s)*

Please include all names or organizations

Contact Name*

First NameLast Name

Donor Recognition*

Please indicate how you wish to be listed in all donor recognition

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone

Please enter a valid phone number.

Donation Type*

Total Pledge Amount*

Number of Pledge Installments*

Installment Schedule*

Date of First Installment*

Date

Gift Amount*

Gift Method*

Number of Pledge Installments (Old)*

Donor Recognition (Old)*

Please indicate how you wish to be listed in all donor recognition