ICCIE

International Center for Captive Insurance Education

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PLEDGE / DONATION FORM

As a 501(c)(3) educational non-profit institution, ICCIE may accept charitable contributions in support of its mission. ICCIE will continue to seek financial contributions as it grows to ensure that the program can be kept up-to-date and to afford the organization the maximum flexibility in program development and curriculum offerings.

Please use the following form to make a donation or a pledge for a future donation:

1. Contributor Information

*First Name
MI
*Last Name
Company Name
(as it should be credited in our materials)

*Billing Address


*
City

*State/Province

*Zip

Country

*Email

*Phone
Would you be willing to serve as a mentor to an ICCIE student?

Can you suggest anyone else who might want to be an ICCIE mentor?

2. Pledge/Donation Amount

*Amount: $
This is a: Pledge Donation

3. Payment Information

(*all fields re required)

Check American Express
Mastercard Visa
Credit Card Number
Expires
if paying by check:
  1. print and fill out this form
  2. mail this form and your check to:

    ICCIE
    2517 Shelburne Road, Suite 2
    Shelburne, Vermont 05482

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