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Add Your Name to the $1000 Plaque!

The Campaign for Virginia

Pledge Form in PDF Format
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To help the University, its schools and its programs achieve their goals, to preserve Jeffersonian ideals for present and future generations, and in consideration of the gifts of others toward its capital campaign goals, I/we hereby agree to give the University of Virginia's Athletic Department the sum of $_______________________________________________in dollars, or the following assets: ______________________________________________________________________________. (Please provide a description of non-cash gifts and estimated value.)

This is an unrestricted gift to the University of Virginia Athletic Department and will be deposited into the Athletics-Special Gifts account*. This type of unrestricted giving allows the department the flexibility necessary to finance construction or renovation of athletic facilities and meet other related needs.

My/our pledge/gift will be paid in the following manner.

  • $___________ amount pledged. $____________ included herewith.

  • The balance to be paid in ______ (#) equal installments beginning _________ and ending ________ (dates).

  • Credit Card Visa/MasterCard)________________________exp____________

  • Other

    In the event of my/our death before completion of the pledge, I/we direct that this commitment _____ shall _____ shall not be honored in settlement of my estate.

    On the plaques at the east and west entrances to Scott Stadium, in publications, and donor honor rolls, I/we wish my/our name(s) (maximum 28 characters per line) to read as follows:

    Name (please print) ___________________________________________________________________

    Social Security Number________________________________________________________________


    Telephone (home)________________________(business)___________________________

  • This gift may be matched by my employer, __________________________________ in the matching ratio of ________ (if known.)

    Please make checks payable to the University of Virginia Rector and Visitors, mail to VSAF, Post Office Box 400833, Charlottesville, Virginia 22904.

    Signature ___________________________________ Date__________________________

    *To be eligible for the recognition plaques, a minimum $1000 gift or pledge and this form must be received on or before December 31, 2001.



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