Payment Method I have enclosed my check made payable to

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Name ®

Address

Mail the completed form to: American Chemical Society Development Office 1155 Sixteenth Street, NW Washington, DC 20036 [T] 202-872-6210 www.acs.org/donate [email protected] ACS Legacy Leaders 



I would like to learn more about becoming an ACS Legacy Leader. I have included ACS in my estate plans. Please send me my ACS Legacy Leader pin.

Corporate Match

My company will match my donation.

Donation in Honor I would like to make a donation: [ ] in honor of

[ ] in memory of

City, State, Postal Code, Country Telephone

Email

Program I would like to support: [ ] ACS Scholars Program [ ] Green Chemistry Education & Outreach [ ] Project SEED [ ] Advancing Chemistry Teaching [ ] Other _______________________

Recognition Level I would like to make my [ ] donation or [ ] pledge at the following level: Elements

($100 — $249)

$ ___________

Catalysts

($250 — $499)

$ ___________

Solutions

($500 — $999)

$ ___________

Iron

($1,000 — $2,499)

$ ___________

Copper

($2,500 — $4,999)

$ ___________

Silver

($5,000 — $9,999)

$ ___________

Gold

($10,000 — $24,999)

$ ___________

Platinum

($25,000 — $49,999)

$ ___________

Other 

$ ___________

I would like to fulfill this pledge with payments of $ _______ over ___ years. (To make a pledge beyond three years, please contact the ACS Development Office.)

Payment Method

Name

I have enclosed my check made payable to the American Chemical Society, or I would like to charge my contribution:

Send a card on my behalf to:

[ ] Visa [ ] Mastercard

[ ] American Express [ ] Discover /

Name

Account Number

Address

Signature

City, State, Postal Code, Country

Gift Amount

Expiration Date

Date

Our Compliance with State Registration: Your donation is very much appreciated. Your contribution to ACS is tax-deductible in the manner and to the extent of the Internal Revenue Code. ACS is designated as a tax-exempt organization as defined in Section 501(c)(3) of the Internal Revenue Code. A copy of our latest financial report may be obtained by writing to the American Chemical Society (attn: Development Office), 1155 Sixteenth Street, NW, Washington, DC 20036, 1-800-227-5558, ext 6210. If you are a resident of one of these states, you may obtain financial information directly from the state agency: FLORIDA – A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE, 1-800-435-7352 (800-HELP-FLA) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE. Florida Registration #CH33806. MARYLAND – For the cost of copies and postage, Office of the Secretary of State, State House, Annapolis, MD 21401 MISSISSIPPI – The organization’s official registration and financial information may be obtained from the Mississippi Secretary of State’s office by calling 1-888-236-6167. Registration by the Secretary of State does not imply endorsement. NEW JERSEY – INFORMATION FILED WITH THE ATTORNEY GENERAL CONCERNING THIS CHARITABLE SOLICITATION AND THE PERCENTAGE OF CONTRIBUTIONS RECEIVED BY THE CHARITY DURING THE LAST REPORTING PERIOD THAT WERE DEDICATED TO THE CHARITABLE PURPOSE MAY BE OBTAINED FROM THE ATTORNEY GENERAL OF THE STATE OF NEW JERSEY BY CALLING (973) 504-6215 AND IS AVAILABLE ON THE INTERNET AT www.njconsumeraffairs.gov/ocp.htm#charity. REGISTRATION WITH THE ATTORNEY GENERAL DOES NOT IMPLY ENDORSEMENT. NEW YORK – Office of the Attorney General, Department of Law, Charities Bureau, 120 Broadway, New York, NY 10271. NORTH CAROLINA – FINANCIAL INFORMATION ABOUT THIS ORGANIZATION AND A COPY OF ITS LICENSE ARE AVAILABLE FROM THE STATE SOLICITATION LICENSING BRANCH AT 1-888-830-4989. THE LICENSE IS NOT AN ENDORSEMENT BY THE STATE. PENNSYLVANIA – The official registration and financial information of the American Chemical Society may be obtained from the Pennsylvania Department of State by calling toll-free, within Pennsylvania, 1-800-732-0999. Registration does not imply endorsement. VIRGINIA – Virginia State Office of Consumer Affairs, Department of Agricultural and Consumer Services, PO Box 1163, Richmond, VA 23218. WASHINGTON – Charities Division, Office of the Secretary of State, State of Washington, Olympia, WA 98504-0422, 1-800-332-4483. WEST VIRGINIA – Residents may obtain a summary of the registration and financial documents from the Secretary of State, State Capitol, Charleston, WV 25305. Registration with any of these state agencies does not imply endorsement, approval or recommendation by any state.