Next Level Mentoring Program
Donation Form
SM
SM
DONATION TYPE (select one)
General
ACT Prep
HBCU Tour
In Kind Doncation
In Memory
In Honor of
For ACT Prep ($250/student) or HBCU Tour ($375/student): Please indicate # of
students you wish to sponsor.
For In Memory or In Honor of Donations: Please include individual’s name and address
with donation form.
Tax Deductible Contribution Enclosed: $
Make all Checks payable to: Next Level Mentoring Program
Next Level Mentoring Program EIN: 20-1765376
Note: If company has a Matching Gift Program, please include your company’s employee
match form with your donation
Mail completed form and donations to:
Next Level Mentoring Program
Attn: Walter Ingram
8459 US 42, #122
Florence, KY 41042
DONOR INFORMATION:
Donor’s Name:
Email Address :
Phone :
__________________
Mailing Address:
_________________________________________
_________________________________________
City:
_______________
State:
Zip:
CREDIT CARD INFORMATION (if applicable):
Name (As it Appears on Card):
Type of Card(select one): ___Visa
___Mastercard ___American Express
___Discover
City:
Zip:
Credit card Number:
Expiration Date:
Billing Address:
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(if different from above)
State:
Knowledge is the catalyst that transforms dreams into reality.SM