The Foundation

Physician Philanthropy in Action

 
Donate Now Print Form

If you would like to make a contribution, please type in the form below, print, and mail completed form with check or money order payable to:


The Foundation of the Pennsylvania Medical Society
Attn: Philanthropy
777 East Park Drive
P.O. Box 8820
Harrisburg, PA 17105-8820

Thank you!

* Required items in the form below.

The Foundation of the Pennsylvania Medical Society Donor Information
*First Name:  
*Last Name:  
Spouse's First Name:
Spouse's Last Name:
*Address:  
*City:  
*State:  
*Zip/Postal Code:   
Country:
Home Phone:
*E-mail Address:   

Donor Company Information

Does your employer match your gifts?


Your Employer:
Business Address:
City:
State:
Zip/Postal Code:  
Country:
Business Phone:
Cell Phone:
Business Fax:
Business E-mail Address
(if different from above:)		  

Other Donor Information (Optional)

Birth Date:
(mm/dd/yyyy)
Medical School or College
(if applicable):
Specialty (if applicable):
Year of Graduation:
Areas of interest within the Foundation:

Enter Credit Card Information

*Name on Credit Card:  
*Type of Credit Card:
*Credit Card Number:    
Card Number (no dashes)

  
3 or 4 digit code found on back of card
*Expiration Date:

Month Year
Designate my gift to:
*Total Amount of Gift /Donation:   
Is this a payment on a previous pledge?
 

Charitable Disclosure Statement:
The Foundation of the Pennsylvania Medical Society is a 501(c)(3) organization. Pennsylvania law requires us to inform you that a copy of the official registration and financial information may be obtained from the Pennsylvania Department of State, Bureau of Charitable Organizations, by calling toll-free within Pennsylvania, (800) 732-0999. Registration does not imply endorsement.