SCCi Donation Authorization

Print this form using your web browser, then fill in the information below. Be sure to write your name exactly as imprinted on the card and to provide your phone number in case we need to contact you to resolve any problems. Thank you for your support!

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Mail the completed form to:

Southeastern Cave Conservancy
PO Box 71857
Chattanooga TN 37407-0857

Please choose a Monthly or Quarterly contribution amount:

Monthly
Amount:

___ $25

___ $20

___ $15

___ $10

Other  $ _______

Quarterly
Amount

___ $75

___ $50

___ $25

___ $15

Other  $ _______
Please specify the duration for your contributions:

Duration:

______
Until Canceled

______ 
Twelve  Months

______
Six Months

___________ Other 

Month to Begin:

_______________, __________
Please fill in your credit card information:

Card Type:

____Visa

___MasterCard

___AmEx

___ Discover

Card Number:

_______________________________________ (typically 16 digits)

Name on Card

__________________________________ (exactly as imprinted on card)
Expiration Date: __________________________________  (as imprinted on card)
Please provide your contact information:
Phone Number: __________________________________  (for confirmation & verification use only)
EMail Address _________________________________________________
Monthly donations of  $10 or more and one-time donations of $250 or more are recognized with an SCCI logo shirt. Please specify your desired shirt size:
Shirt Size: _____________________

I hereby authorize the Southeastern Cave Conservancy, Inc. to charge my account in the amount and for the duration indicated above.

Signature: ________________________________________ Date: _________________

Your donation is tax deductible in accordance with IRS rules for charitable contributions. The SCCI is a 501(c)3 tax-exempt non-profit organization, and donations are normally fully deductible. This form and your credit card statements serve as proof of your donations. Each charge is treated by the IRS as a separate donation.

Mailing address (please print):

______________________________________________

______________________________________________

______________________________________________