Donation Form in Honor of Ernie Schoch’s Retirement Your GiftGift amount:$500$250$100$50Other Amount: Tribute Gift forErnest SchochIn Honor of Ernie Schoch's Retirement Please notify the following person of my giftName:First name: Last name: Country: ANTIGUA AND BARBUDAARGENTINAAUSTRALIAAUSTRIABAHAMASBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBERMUDABHUTANBOLIVIABOSNIA AND HERZEGOVINABRAZILBRITISH VIRGIN ISLANDSBULGARIABURKINA FASOCAMEROONCANADACHILECHINACOLOMBIACOLUMBIA (DO NOT USE)CONGOCOSTA RICACOTE D'IVOIRECROATIACUBACYPRUSCZECH REPUBLICDEMOCRATIC REPUBLIC OF THE CONGODENMARKDOMINICAN REPUBLICECAUDOREL SALVADORETHIOPIAFINLANDFRANCEGEORGIAGERMANYGHANAGREAT BRITIANGREECEGUINEA-BISSAUHONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRELANDISRAELITALYJAMAICAJAPANJORDANKENYALEBANONLITHUANIALUXEMBOURGMALAYSIAMAURITANIAMEXICOMOROCCONETHERLANDSNEW ZEALANDNIGERIANORWAYOMANPAKISTANPALESTINEPANAMAPARAGUAYPHILLIPPINESPOLANDPUERTO RICORUSSIASAUDI ARABIASENEGALSERBIASIERRA LEONESINGAPORESLOVENIASOUTH AFRICASOUTH KOREASPAINSRI LANKASUDANSWEDENSWITZERLANDSYRIATAIWANTHAILANDTRINIDAD AND TOBAGOTUNISIATURKEYUGANDAUNITED ARAB EMIRATESUNITED KINGDOMUNITED STATESVENEZUELAVIETNAMYEMENZAMBIA Address:City: State & zip:State: stateN/AAAABAEAKALAPARASAZBCCACOCTCZDCDEFLFMGAGUHIIAIDILINKSKYLAMAMBMDMEMHMIMNMOMPMSMTNBNCNDNENHNJNLNMNSNTNUNVNYOHOKONORPAPEPRPWQCRISCSDSKTNTXUTVAVIVICVTWAWIWVWYYT Zip: City & county:City: County: county (optional)Surrey KT11 2DSWest SussexSalvadorHertfordshireNorth YorkshireWiltshireHampshireSurreyLincolnshireMiddlesexFIFEKent Postcode: City: Province & postal:Province: provinceN/AAAABAEAKALAPARASAZBCCACOCTCZDCDEFLFMGAGUHIIAIDILINKSKYLAMAMBMDMEMHMIMNMOMPMSMTNBNCNDNENHNJNLNMNSNTNUNVNYOHOKONORPAPEPRPWQCRISCSDSKTNTXUTVAVIVICVTWAWIWVWYYT Postal: Suburb: State & postcode:State: stateN/AAAABAEAKALAPARASAZBCCACOCTCZDCDEFLFMGAGUHIIAIDILINKSKYLAMAMBMDMEMHMIMNMOMPMSMTNBNCNDNENHNJNLNMNSNTNUNVNYOHOKONORPAPEPRPWQCRISCSDSKTNTXUTVAVIVICVTWAWIWVWYYT Postcode: Suburb: suburbChinaQING DAO 266012Xi Cheng DistrictWairarapa, North IslandWairarapa, City & post code:City: cityQING DAOHONG KONGNORTH POINT, HONG KONGNORTH POINTBEIJINGBEIJING 100031North Island Post code: DesignationWesttown Fund - Area of Greatest NeedWesttown Fund for the ArtsWesttown Fund for AthleticsWesttown Fund Supporting Anti-Racism WorkWesttown Fund for Campus CareWesttown Fund for Faculty SupportWesttown Fund for Financial AidWesttown Fund for Student Programs and ServicesWesttown Fund for Full AccessWesttown Fund for Technology other Leave a comment (optional):Billing AddressOrganization name: Name: Title: First name: Last name: Email: Cell Phone: Country: ANTIGUA AND BARBUDAARGENTINAAUSTRALIAAUSTRIABAHAMASBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBERMUDABHUTANBOLIVIABOSNIA AND HERZEGOVINABRAZILBRITISH VIRGIN ISLANDSBULGARIABURKINA FASOCAMEROONCANADACHILECHINACOLOMBIACOLUMBIA (DO NOT USE)CONGOCOSTA RICACOTE D'IVOIRECROATIACUBACYPRUSCZECH REPUBLICDEMOCRATIC REPUBLIC OF THE CONGODENMARKDOMINICAN REPUBLICECAUDOREL SALVADORETHIOPIAFINLANDFRANCEGEORGIAGERMANYGHANAGREAT BRITIANGREECEGUINEA-BISSAUHONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRELANDISRAELITALYJAMAICAJAPANJORDANKENYALEBANONLITHUANIALUXEMBOURGMALAYSIAMAURITANIAMEXICOMOROCCONETHERLANDSNEW ZEALANDNIGERIANORWAYOMANPAKISTANPALESTINEPANAMAPARAGUAYPHILLIPPINESPOLANDPUERTO RICORUSSIASAUDI ARABIASENEGALSERBIASIERRA LEONESINGAPORESLOVENIASOUTH AFRICASOUTH KOREASPAINSRI LANKASUDANSWEDENSWITZERLANDSYRIATAIWANTHAILANDTRINIDAD AND TOBAGOTUNISIATURKEYUGANDAUNITED ARAB EMIRATESUNITED KINGDOMUNITED STATESVENEZUELAVIETNAMYEMENZAMBIA Address:City: State & zip:State: stateN/AAAABAEAKALAPARASAZBCCACOCTCZDCDEFLFMGAGUHIIAIDILINKSKYLAMAMBMDMEMHMIMNMOMPMSMTNBNCNDNENHNJNLNMNSNTNUNVNYOHOKONORPAPEPRPWQCRISCSDSKTNTXUTVAVIVICVTWAWIWVWYYT Zip: City & county:City: County: county (optional)Surrey KT11 2DSWest SussexSalvadorHertfordshireNorth YorkshireWiltshireHampshireSurreyLincolnshireMiddlesexFIFEKent Postcode: City: Province & postal:Province: provinceN/AAAABAEAKALAPARASAZBCCACOCTCZDCDEFLFMGAGUHIIAIDILINKSKYLAMAMBMDMEMHMIMNMOMPMSMTNBNCNDNENHNJNLNMNSNTNUNVNYOHOKONORPAPEPRPWQCRISCSDSKTNTXUTVAVIVICVTWAWIWVWYYT Postal: Suburb: State & postcode:State: stateN/AAAABAEAKALAPARASAZBCCACOCTCZDCDEFLFMGAGUHIIAIDILINKSKYLAMAMBMDMEMHMIMNMOMPMSMTNBNCNDNENHNJNLNMNSNTNUNVNYOHOKONORPAPEPRPWQCRISCSDSKTNTXUTVAVIVICVTWAWIWVWYYT Postcode: Suburb: suburbChinaQING DAO 266012Xi Cheng DistrictWairarapa, North IslandWairarapa, City & post code:City: cityQING DAOHONG KONGNORTH POINT, HONG KONGNORTH POINTBEIJINGBEIJING 100031North Island Post code: Payment detailsPayment Processed by BlackbaudCardholder name: Card number: Card type:<Please Select>VisaAmerican ExpressDiscoverMasterCard Expiration:Month: month010203040506070809101112 Year: year202220232024202520262027202820292030203120322033203420352036 CSC: Is the information you entered to set up the Direct Debit Instruction correct?Account holder: Sort Code: Account number: Amount to be debited: Collection frequency: Date of first gift: FormField
