Full Name ________________________________________

Firm / Organization ______________________________

Firm / Organization Address ______________________

__________________________________________________

City _________________ State _____ Zip ___________

Phone Number __________________

Fax Number ____________________

Email Address ______________________________

Web Address _______________________________

Amount of Donation ____________

MasterCard / Visa (please circle one)

Name on Card ____________________________________

Card Number _____________________________________

Expiration Date _______________________ 3-Digit Verification Code ________

Signature _____________________________

Thank you for supporting The Impact Fund. A confirmation letter
acknowledging your donation will be mailed to you.