Foresight Institute
Challenge Grant Donation Form

PRINT and fax or mail this form to:
Foresight Institute, Box 61058
Palo Alto CA 94306 USA
Tel: 650-917-1122 Fax: 650-917-1123

___  Yes, I support the Foresight effort! Keep me informed about Foresight's work over the next year. Here is my donation or new membership which will be doubled through the challenge grant. Foresight is a nonprofit organization; donations are tax-deductible in the U.S. to the full extent permitted by law.
This Challenge Grant donation is for:

One-time Donation:
  ___  $100
  ___  $500
  ___  $1000
  ___  other (please enter amount:  $_________)

New Basic Foresight Membership:
  ___  $60

New Foresight Senior Associate Membership:
  ___  Associate: $250 annually for five years
  ___  Fellow: $500 annually for five years
  ___  Colleague: $1000 annually for five years.
  ___  Friend: $5000 annually for five years.

Renewal of Senior Associate status after fulfilling a 5-year pledge:
  ___  Associate: $250 annually for five years
  ___  Fellow: $500 annually for five years
  ___  Colleague: $1000 annually for five years.
  ___  Friend: $5000 annually for five years.

Upgrading to a higher membership level for the remainder of my five-year Senior Associate term. I am upgrading to the level indicated below (either Fellow, Colleague, or Friend).
  ___  Fellow: $500 annually for five years
  ___  Colleague: $1000 annually for five years.
  ___  Friend: $5000 annually for five years.

Please confirm the amount to charge your credit card:  $_________

    ___  A matching gift will be made by my company
   
Contact Information

Title: ______  First Name(s): ___________________

Last Name: _________________________

Address: ___________________________________

Address: ___________________________________

City, State: ___________________________________

Zip/Postal Code, Country: _________________________

Phone: __________________   Fax: __________________

Email: ___________________________________

Payment Information

Name on credit card:_______________________________

VISA or Mastercard Number:________________________________

Exp. Date:_________ (Month/Year)

Signature________________________________
My donation is enclosed, payable to the Foresight Institute. Foresight is a nonprofit organization; donations are tax-deductible in the U.S. to the full extent permitted by law. Donations can be made by check from a U.S. bank, postal money order, VISA, or Mastercard (AMEX not accepted). Credit card donations may be sent by fax. You will receive a receipt for your tax-deductible donation.

To discuss major gifts or ask questions, contact Foresight at 650-917-1122.

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Last updated 26 November 2002. The URL of this document is: http://www.foresight.org/Challenge2002/donation.html