American Name Society

YES, I would like to contribute to the Kelsie B. Harder Memorial Fund.  I understand that my contribution will be used in support of the educational programs of the American Name Society.

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Name (please print)                                                            Signature                                                                                                

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Mailing Address

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Email (optional) _______________________________________  

Please make checks payable to The American Name Society or

To contribute by Credit Card please complete the following:

Please Charge my Credit Card as follows:

Check One:

• American Express                                  

• Master Card                                         

• Visa                                                      

• Discover                                                

Amount in U.S. Dollars: ________________

Card Number: _____________________________  Expiration Date: ______________

Name (please print as shown on card):________________________________________

Signature: ________________________________________________________

Print and complete this form and send it to:

Michael F. McGoff, Vice Provost

Office of the Provost

Binghamton University

State University of New York

Binghamton, New York 13902-6000