Medical Conference Center Online Giving Form

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Thank you for your commitment to help create a Medical Conference Center that will be the centerpiece of our academic activities for years to come.

Gift Information (Physicians Circle Benefits)

$500    (only $20 per pay period).
$1,000 (only $40 per pay period).
$2,000 (only $80 per pay period).
My special gift $

Gift Payment Options (please select one) 

I wish to make an on-going payroll deduction gift.

  • Employee ID:
  • Birthday: (mm/dd/yyyy)*
    Please deduct $ from my paycheck for the next pay periods.
    ~ There are 26 equal periods in one year. We will begin deductions with the next full pay period following receipt of this form by the CSM Foundation.

I wish to pay in full at this time.

  • Please charge my American Express Discover Mastercard Visa
    Credit Card Number Exp. Date
    Name as it appears on card

I wish to pledge my gift.

  • Please bill me (select one) July 2011 December 2011
Physicians Circle Information 

You will receive recognition on the Physicians Circle donor display in the Medical Conference Center at CSM Milwaukee and at CSM Ozaukee for one year with your gift of $500 or more. Your gift of $1,000 or more will also receive Benefactors Society recognition at the CSM Milwaukee and CSM Ozaukee hospitals.

Recognition Information 

Please indicate how you would like to be listed:

Contact Information 









Authorization Statement 

I authorize Columbia St Mary's Foundation to process this payment information. If payment is pledged, I authorize Columbia St Mary's Foundation to process payments on the 15th of the month on the above basis starting from the date this pledge was received.



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