SUPPORT
Yes! I want to support PCNY's campaign
to strengthen and empower the Panamanian
communities. Enclosed is my gift to PCNY
for $ for the following category

[] Mr. [] Mrs. [] Ms. [] Dr. [] Mr. and Mrs.

First Name: ________________________________

Last Name: ________________________________

Address: [] Home [] Business

Street Name: _________________________________________________________

City ______________________      State ____    Zip ______________________

Office Phone ______________________     Home Phone ____________________________

Fax _______________________ Email ______________________________

Business Title ___________________    Business Affiliation ___________________________

I am pleased to join the Chairman’s Circle as a:

[ ] $5,000 Benefactor

[ ] $2,500 Patron

[ ] $1,500 Supporter

[ ] $1,000 Sustainer

[ ] $500 Contributor

[ ] $250 Donor

[ ] $100 Help

[ ] $50 Friend

[ ] Check enclosed made payable to PCNY $ ________________

[ ] Please charge $ ________________ to my [ ] Visa  [ ] MC  [ ] AmEx

Card # __________________________________________ Exp. Date ___________

 3-digit code: ______

Signature ____________________________________________________

If paying by credit card, you may FAX this form to 718-852-7333
or visit www.panamacouncilny.coms to sign up for your membership.

[ ] We would like to donate $ _______________________________ to PCNY

[ ] I prefer not to receive any benefits that would reduce the tax-deductibility of my gift.

Please send me information about:
[ ] including the PCNY in my Will or Trust
[ ] making stock gifts to the PCNY
[ ] giving a PCNY membership

Does your company have a matching gift program?
Check with your Human Resources Department to see if you can increase your support to the PCNY.

[ ] if Yes, please indicate the contact information of your Human Resources Department

Name: _____________________________________________________

Business: ___________________________ Business Title _________________________

Street Name: _________________________________________________________

City __________________________ State _______ Zip _______________

Office Phone ______________ Fax _______________ Email ________________________

Panamanian Council of New York, Inc.
Attn: Chairman’s Circle
94 South Oxford Street, Brooklyn, NY 11217
Tel: 718-625-0471 [ ] Fax: 718-852-7333 [ ] Website: www.panamacouncilny.com