Donor Campaign

Annual Fund Pledge Form
Thank you for making a gift to the Ponce School of Medicine Alumni Association.

If you have any question please call the Alumni Affairs Office at 787-840-2575 or email: alumni@psm.edu

NOTE: The fields below marked with an "*" must be completed to process this form.
 
Name      
       
*First:   *Last:  
Middle:      
*Program:   *Specialty:  
*Certifications:   *Year of Graduation:  
       
Home
Address		      
       
*Street:   *City:  
*State:   *Zip Code:  
       
Work
Address		      
       
Street: City:
State: Zip Code:
       
Phone
Number		      
       
*Home:   Business:
Email:      
       
       
Gift Information:    
Scholarship Fund Contribution Categories    
       
Caduceus Club ($1000+)    
Founders Club ($500+)    
Patrons Club ($250+)    
Century Club ($100+)    
Contributors ($25 to $99)    
 
       
*Payment Type
       
Send check to:
      Ponce School of Medicine Alumni Office
      PO Box 7004
      Ponce, PR 00732-7004
 
       
For payment with credit card: Please call at 787-840-2575 ext. 2107 for information and instructions.
       
Please check the information above and verify that it is correct.
       
       
Please click the Submit button below to make gift or click Reset to clear the form's contents.
       
       

THANK YOU FOR YOUR SUPPORT OF THE
PSM ALUMNI ASSOCIATION ANNUAL FUND!