Donor Form  for Maquoketa Valley Dollars for Scholars                                                                                                                                                                                                                                  P. O. Box 186                                                                                                                                                                                                                                                                                                            Delhi, IA 52223

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Checks payable to:  M.V. Dollars for Scholars

Total amount of contribution:  $____________

Please specify how to apply your contribution:

     Endowed Scholarship Fund

              Endowment Name: _____________________  Amount: $__________________

      Direct Scholarship Fund

             Scholarship Name: _____________________  Amount: $ __________________

              This is made in HONOR of ___________________________________________      

                                       in MEMORY of __________________________________________  

                                       in CELEBRATION of _____________________________________

Donor Name: ___________________  Address: _________________________________

We recognize these cumulative levels of support:                                                                                                                                                                                                                                                      $5.000 Mentor and/or Named Endowment                                                                                                                                                                                                                                                                 $1.000—$4,999    Scholar                                                                                                                                                                                                                                                                                         $500— $999       Graduate                                                                                                                                                                                                                                                                                      $250—$499        Senior                                                                                                                                                                                                                                                                                       $100—$249        Junior                                                                                                                                                                                                                                                                                                  $50—$99            Sophomore                                                                                                                                                                                                                                                                                     $25—$49            Freshman                                                                                                                                                                                                                                                                                            up to $24             Supporter

Your support at any level is greatly appreciated and the earnings from Endowed Funds and Direct Scholarships will be distributed to the graduates of Maquoketa Valley                                           in the form of scholarships.

Thank you !!!

Please send completed form and check to MVDFS at the above address.