I (we) want to support Piedmont CASA with a gift of:
Dollar Amount:	.00
Name (as it appears on your card):
Address 1:
Address 2:
City:	State:    Zip:
Phone with area code:	Will be used only if there is a question about this gift
Email Address:
Our Contributor categories are:
Pacesetter: $5,000+ Ambassador: $2,500-$4,999 Benefactor: $1,000-$2,499     Patron: $500-$999 Friend: $100-$499 Donor: $1-$99
Credit Card type:	MasterCard Visa American Express
Credit card number:
Expiration date:	mm         yyyy
Card name and address if different than above:
Name(s) as you wish it published:
	I prefer not to have my name published
In Memory of:
In Honor of:
Matching Gift / Employer Name:

No goods or services were exchanged for this charitable donation, which is tax deductible for Federal income tax purposes. A financial statement is available upon written request from the Virginia Department of Agriculture, Office of Consumer Affairs.