Date: __________________

Recognition Name: __________________________________

                                  (How you wish to be publicly acknowledged)

Contact Name: _____________________________________

Title: _____________________________________________

Company Name: ____________________________________

Street Address: _____________________________________

City: ________________  State: __________ Zip: _________

Phone Number: ________________________

Fax Number: __________________________

Email Address: ________________________

Gift Amount: $____________

PAYMENT INFORMATION

Check Enclosed: □  (payable to Pointe of Departure)

Thank You!

Pointe of Departure is a non-profit 501c(3) corporation, tax identification number: 34-1947132

Donations are tax-deductible as allowed by law.

Please mail form and payment to:

Pointe of Departure

PO Box 720455

San Jose, CA  95172-0455

www.pointeofdeparture.com