piedmont 163 west b street kannapolis, nc 28081...

CONTRIBUTION  FORM  

DanceTheatre PIEDMONT  Ce lebrating 13 years of excell ence in dance! Rebecca Wiley, Artistic Director

163 West B Street Kannapolis, NC 28081 PiedmontDanceTheatre.com 704.932.8888

First  Name________________________________    Last  Name  _______________________________  

Address  ___________________________________________________________________________  

City  ___________________________________    State  _______    Zip  Code  ______________________  

Email  Address  _____________________________    Phone  Number  ___________________________  

Name/s  as  you  wish  to  appear  in  PDT  publications  ________________________________________  

CORPORATE  GIVING  I  wish  to  contribute  to  PDT  with  a  gift  of  $  ______________  (Please  check  one)  

PAYMENT  OPTIONS  Please  choose  one  of  the  following  payment  options:  ____  I  would  like  to  charge  my  contribution  to  my  credit  card.  

____  Visa  or  ____  Master  Card  Card  Number  _______________________________________    Exp  Date  _______________  Signature  __________________________________________    Today’s  Date    ___________  

  ____  Please  charge  the  entire  amount  at  once.     ____  I  wish  to  arrange  a  payment  plan.  Please  charge  my  credit  card:       ____  Semi  Annually   ____  Quarterly   _____  Monthly    ____  I  am  enclosing  a  check  payable  to  Piedmont  Dance  Theatre    ____  My  Company  has  a  Matching  Gift  Program:     ____  I  am  enclosing  the  completed  form.   ____  I  will  mail  the  completed  form  to  PDT.  

PLEASE  MAIL  COMPLETED  FORM  TO:  Piedmont  Dance  Theatre    

163  West  B  Street  |  Kannapolis,  NC  28081  

____  Production  $1,000  +  ____  Principal  $500  +    

____  Presenting  $5,000  +  ____  Artistic  $2,500    +    

____  Director’s  Circle  $10,000  +    

INDIVIDUAL  GIVING  I  wish  to  contribute  to  PDT  with  a  gift  of  $  ______________