Your Name:
Title/Position:
Organization:
Address:
City: State: Zip:
Phone: Fax:
Email:
Website URL:

Donation amount:

$100
$250
$500
$1000
$2500
Other contribution ____________

Please charge my: Visa Master Card

card____________________ exp. date______________

signature _______________________________________

Donations are tax deductible as allowed by law. Financial statements are available upon request.

Mail form and contribution to:

Gathering Waters Conservancy
211 S. Paterson St., Suite 270
Madison, WI 53703