Donation Information
Amount:	$     *
Additional Information
Type of gift:	One-time gift Recurring gift
Frequency:	Weekly Monthly Quarterly Annually On:   Sunday Monday Tuesday Wednesday Thursday Friday Saturday Starting:    Ending: (leave blank for continuous)   Ending:
Corporate:	This donation is on behalf of a company.
Anonymous:	I prefer to make this donation anonymously.
Comments:
Donor Information
Title:	<Please select> Mr. Mrs. Mr. and Mrs. Ms. Dr. Dr. and Mrs. Dr. and Mr. Drs. Assemblyman Captain Colonel Congressman Congresswoman General Governor Judge Lieutenant Major Mayor Mr. and Ms. Ms. and Mr. Rabbi Reverend Senator The Assemblywoman . Dean Sgt. Br. The Hon. The Rev. Miss The Most Rev. Sr.	*
First name:		*
Last name:		*
Country:	United States Canada	*
Address lines:		*
City:		*
State:	<Please Select> AA AE AL AK AB AS AP AZ AR BC CA CZ CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MB MH MD MA MI MN MS MO MT NE NV NB NH NJ NM NY NL NC ND MP NT NS NU OH OK ON OR PW PA PE PR QC RI SK SC SD TN TX UT VT VI VA WA WV WI WY YT AUS	*
ZIP:		*
Phone:		*
Email:		*
Payment Information
Cardholder's Name:		*
Card Number:		*
Card Type:	Visa American Express Discover MasterCard	*
Card Expiration:	01 02 03 04 05 06 07 08 09 10 11 12  / 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040	*
Card Security Code:		*
Dedication
If this gift is in honor or in memory of someone, please complete this section.
Type:	in honor of in memory of	*
Name:		*
First name:
Last name:		*
	Notify the honoree on my behalf.	*

 For assistance, please call (518) 262-3322 and an Albany Med Foundation representative will assist you.

A copy of our most recently filed financial report is available from the Charities Bureau Registry on the New York State Attorney General’s website (www.charitiesnys.com) or, upon request, by contacting the New York State Attorney General, Charities Bureau, 28 Liberty Street, New York, NY 10005, or us at 43 New Scotland Avenue-Mail Code 119, Albany, New York 12208. You also may obtain information on charitable organizations from the New York State Office of the Attorney General at www.charitiesnys.com or (212) 416-8401.