Donations Form

Please fill out this form, print it and send it with your check, money order or credit card information to:

Department of Chemical Engineering

PO BOX 9046

Mayagüez PR 00681-9046

Please provide the following contact information:

   
Name   First Last
Organization
Street Address
Address (cont.)
City Zip/Postal Code
State/Province
Country
Work Phone --   E-mail:

Please direct my gift to one of the following options:

                    

Please specify quantity of Gift:

 $2500    $1000    $500    Other $

Please fill out payment information:

  Check or Money order              Visa              Master Card              Amex

 

Card Holders Name

 

Card Number**

 

Card Verification Number *

 

Expiration Date

 

 

 

Authorized Quantity

 

Signature

 ________________________________

         

*The card verification number is a 3-digit number printed on the back of your card. It appears after and to the right of your card number. 

**The purpose of this formulary is for the convenience for all the people who want to send by mail their registration information and fee. It is important to appoint that the person whose signature for the credit card authorization is on the formulary, that The University of Puerto Rico is not responsible for missing mail and the fraudulent use of the credit card before we receive the payment.

Copyright © 2006 [UPRM Department of Chemical Engineering]. All rights reserved.
Revised:06/14/06