Secure Credit Card Gift Form

To make a credit card donation online using our secure server, please completely fill out all appropriate boxes below and click Authorize Transaction.

Fields marked with an asterisk (*) are required.

Name: * *
  First MI Last
Home mailing address: *
City of residence: *
State: *  ZIP: *
Home Telephone: *
Business Telephone:
Spouse’s Name:
Best way to reach me is by:

I am an alumnus/alumna
  Your class year:
This is a joint gift with my spouse.
I would like to receive information about wills, bequests and estate planning.

This gift is to be credited:
In my name only.
Jointly with my spouse.
As a pledge payment.
My employer matches gifts.
Please let me know if my employer matches gifts.
Please use my gift for:
Presidential Inauguration
Annual fund.
Undergraduate scholarships.
Spiritual Life.
Kentucky College of Osteopathic Medicine.
KYCOM Medical Mission Team
(Dominican Republic Mission Trip).
Specific scholarship fund (please indicate below).
Other special instructions (please indicate below).
In honor of (please indicate below).
In memory of (please indicate below).
Alumni weekend (please indicate below).

Amount of gift: *
Name (EXACTLY as it is on your credit card): *
Please select credit card type: *
Credit Card Number: *
Expiration Date: *
3 Digit Security Code: *
One time gift
Recurring gift
If this is a recurring gift, how often do you want us to charge your credit card?
Gift directions/comments:
If this transaction is for Alumni Weekend, please indicate that here:

By clicking Authorize Transaction I understand that I am authorizing the University of Pikeville to charge the above credit card with the amount specified in this document.