Safe Spaces II Pledge Form

Name *

First

Last

Preferred Name

(Optional)

Email *

Email

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Phone

Mailing Address: *

Pledge Amount: *

TOTAL Pledge Amount

This pledge will be paid *

At one time (enter date below)
In monthly installments over three years (enter start date below)
In quarterly installments over three years (enter start date below)
In annual installments over three years (enter start date below)
Other (enter comments below)

Please be specific about your desired payment schedule.

Start Date for Payments/Other Payment Schedule *

Please be specific about the date of your initial payment, or the specific payment dates and amounts for your pledge.

Signature of Intent to Pledge *

By initialing above, I/(we) convey my/(our) pledge to contribute cash and/or assets in "Pledge Amount" to the Concord Coalition to End Homelessness 3-year Safe Spaces II: The Next Step campaign.

Referring Organization *

Is your pledge a part of a group effort (workplace, church, other organization)? If so, list their name here.

My company will match my donation

YES

Please mail or email your completed company match form to: office@concordhomeless.org OR CCEH, PO Box 3933, Concord, NH 03302

This pledge is made

In honor of
In memory of

Please enter name below.

In honor of/memory of name

Please enter the name of the person you would like to honor with your gift.

Please enter notification Name(s) and Address(es) for your In Memory of/In Honor of donation

CCEH will notify those listed above about your IMO/IHO donation.

CCEH may recognize me and my contribution in printed or electronic materials

YES
NO

Would you like to sign up for CCEH's monthly e-newsletter to read about what CCEH is doing in the community?

YES
NO

You can easily unsubscribe at any time!

Thank you for committing to help CCEH provide essential services to those experiencing homelessness in our community, and work toward our goal of insuring everyone has a stable, safe, affordable and decent place to call home.