Q90 FM WORQ 90.1

• First Name *
• Last Name *
• Address *
• City *
• State *
• Zip *
• Phone * (ex: 555-555-5555)
• Birthday (ex: mm/dd/yyyy)
• Email *
• Have you given to Q90 before? Please Select Yes No Not Sure

• I pledge my support in the following way * Please Select One Time Pledge of Monthly Pledge of Q-Club Member Full Day Sponsor Half Day Sponsor

• One Time Pledge of *

• Monthly Pledge of *

• Q-Club Member * Please Select $27.00 Per Month $162.00 One Time

• Full Day Sponsor * Please Select $75.00 Per Month $450.00 One Time
• Desired Date

• Half Day Sponsor * Please Select $38.00 Per Month $228.00 One Time
• Desired Date

• Would you like this pledge to be automatically renewed at every Q-drive? Please Select Yes No
• Additional Comments

• Please Select I will Send Payment In The Mail Automatically Withdraw From Checking Account

A permission form will be mailed to you.

• Employer
• Spouse's Employer Why?
Some companies offer matching gifts, costing you nothing, but helping the Q greatly.