Please print this page, complete form and mail.
Date ____/____/____
Name _________________________________________________________________________
Address _______________________________________________________________________
City/State/Zip __________________________________________________________________
Phone (______ )_________________ E-mail _________________________________________
Donation Amount
I want to invest in the future of Pregnancy Support Center of Ulster County and a brighter future in general for those needing their services!
Here’s my tax-deductible donation of:
$25_____ $30_____ $50_____ $100_____ $250_____ $500_____ $1000_____
Other amount $________________
Method of Donation
Credit Card ____MasterCard ____Visa ____Discover ____American Express
Name on Card ________________________________________________________________
Card Number _________________________________________________________________
Exp. Date (mm/yy) _____________________ Secure Code (three digits): ________________
Signature ____________________________________________________________________
Checks or Money Orders Payable to Pregnancy Support Center
Mail Donation and Completed Form
Pregnancy Support Center of Ulster County
246 Main St. Suite 9
New Paltz, NY 12561
The Pregnancy Support Center of Ulster County is a 501(c)(3) not-for-profit organization
and your donation is tax deductible. We appreciate your support!