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Personal Information

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Address:

 
Address 2:

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Gift Amounts and Details
I would like to give to the...                                          (Note: Please refrain from using commas)

Annual Fund, the amount of:    
Theta Xi Scholarship Fund, the amount of:  
Warrior Club, the amount of:  
Momentum Campaign, the amount of:  
Parents' Fund, the amount of:  
Senior Class Gift , the amount of:  
Established scholarship of:  
... in the amount of:    
I would like to make my Alumni dues payment of $20  
I would like to make this gift in memory of:  
My total gift amount today is:    
Special Notes or Designations:  
Credit Card Information
Note: All information must be entered exactly as it is on your credit card.
 

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The Card Validation Code is a three digit number found in the signature area on the back of your credit card.  The three digit number is displayed after your credit card number.  American Express four digit CVC appears on the front of the card under the card number.

Expiration Date:

 Ex: mm/yy  

Name on Credit Card:

 
Amount to Charge:  $
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NOTE: I certify that all information provided is correct. By submitting this form, I authorize Indiana Tech to charge the specified amount and for the purpose indicated.  Please be advised that any errors in processing are the sole responsibility of the cardholder.  Disputes of transactions may result in additional processing fees to the cardholder.  If you believe you have made an error, please contact Indiana Tech immediately for resolution.
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