Church Woods Pledge Form

Contact Information:   Mr.__   Mrs.__   Ms.__  Mr.&Mrs.__   Dr.__

Name:____________________________________________________________

Address:____________________________________________________________

City:_________________ Prov:_________________ Code: ________________

E-mail:______________________________ Phone:_________________________

Pledge Information:  I wish to pledge support at the following level:

• Guardian of the Woods ($50,000 plus)
• Forest Oak ($20,000 to $49,999)
• Ancient Maple ($10,000 to $19,999)
• Silver Birch ($2,500 to $9,999)
• Butternut ($500 to $2,499)
• Cedar (Other) $_____________

I pledge a total gift of $________________________________________

Contributions in any amount are much appreciated. All donors over $100. will be recognized on a permanent sign in the Woods. Please tell us the wording we should use to recognize your gift:

____________________________________________________ (eg. Mr. & Mrs. Robert W. Jones)

If you prefer your donation to remain anonymous, please check here: ____

Enclosed is my payment of : $____________________

Please request my pledged payment: - Sept. 15/06 (6 weeks before property closing)  Other:____________________

All funds received will be held in a special Church Woods account pending completion of the property transaction, and will be returned if the project does not proceed. Charitable tax receipts will be issued at year-end. The Couchiching Conservancy is registered charity No. 13972-5030 RR0001. If you would prefer to donate stocks of other securities, please contact us for more information.

My gift is designated for the purchase and stewardship of Church Woods.