[[ The NCPA Foundation ]]

NCPA Foundation
100 Daingerfield Road
Alexandria, VA 22314
Tel: 800.544.7447
or 703.683.8200
Fax: 703.683.3619
info@ncpafoundation.org

The NCPA Foundation is committed to supporting the growth and advancement of independent community pharmacy. A gift to the NCPA Foundation will help support low-interest educational loans and scholarships to pharmacy students in need, critical research and programs to improve the success of independent pharmacy, and financial aid to community pharmacy owners for their recovery in the event of disaster, accidents, or illness. For a complete description of the Foundation's activities, see the Foundation Annual Report.

The NCPA Foundation is a nonprofit 501(c)(3) organization. Contributions and gifts to the NCPA Foundation are generally deductible as charitable contributions for federal tax purposes. (Federal Tax ID 36-6772250)

Fields marked with an * are required.

Donation Designation:
Unrestricted
NCPA Pruitt-Schutte Student Business Plan Competition Endowment Fun
Presidential Scholarship for Academic and Leadership Excellence
Neil Pruitt, Sr. Memorial Scholarship
J.C. and Rheba Cobb Memorial Scholarship for Excellence in Government Affair
Willard B. Simmons, Sr. Memorial Scholarship for Excellence in Pharmacy Management

* Donor Level

Individuals		Corporations
	Leadership Series
$		$
5,000 and above	Visionary	50,000 and above
2,500-4,999	Futurist	25,000-49,999
1,000-2,499	Catalyst	10,000-24,999
500-999	Strategist	5,000-9,999
	Friends of the Foundation
$		$
250-499	Fellows	2,500-4,999
100-249	Patrons	1,000-2,499
Gifts up to $99	Associates	Gifts up to $999

Donor Designation

I would like to make a monthly donation.
Please bill my credit card monthly in the amount of $

I would like to make a annual donation.
Please bill my credit card annually in the amount of $

Please bill my credit card the one time amount of $

Charge my:
American Express | Discover | MasterCard | Visa

Please contact me regarding a Planned Gift to memorialize my legacy. Remembering the NCPA Foundation in your will automatically includes you in the elite NCPA Foundation Legacy Society.

Please indicate if your contribution is designated for a Memorial, Honorary, or Special Occasion gift:
	In Memory of:
	In Honor of:
	On the Occasion of:

Please provide your name as you would like it listed in the NCPA Foundation Annual Report and check your preference for individual or company name:
	Name
	Company
	Address
	City	State Zip
	Telephone
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Please enter your credit card information here:
	Name on Card
	Card Number
	Card Expiration	Security Code*
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	*Security code is the three-digit number on the back or four-digit number on the front of your credit card.