Full Name:required

Address 1required

Address 2

Cityrequired

Staterequired

Ziprequired

Email:required

Please designate my gift to (1 to 3 areas will be distributed evenly):

Fund Area

Please Specify Other:

Fund Area 2

Please Specify Other:

Fund Area 3

Please Specify Other:

Payroll deduction amount per pay period:required

Please choose ONLY ONE of the following:

I authorize HGP to deduct the above amount each pay period until I provide instructions to stop (automatic renewal). Beginning Date: (mm/dd/yyyy)

OR

I authorize HGP to deduct the above amount each pay period for this period of time:

Beginning Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

Please Initial:required