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Fund the Mission

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					                                             Presented by Wells Fargo



                             Fund the Mission Commitment Form
   In an average week in Texas, over 1,000 babies are born prematurely, many so small they must fight for their
  lives. Your Fund the Mission gift is a contribution to the March of Dimes research, programs, and education that
                                 make a difference in the lives of our tiniest Texans.


                                              Donation Amounts
                                                    (circle one)


$15,000 ___ $10,000 ___ $5,000 ___ $2,500 ___ $1,000 ___ $500 ___ Other $___

  Charge my credit card one time for the total donation amount indicated above.

  Charge my credit card in 5 monthly installments (May through September) to total the
   amount indicated above.


Name

Individual Contact

Address

City ___________     State         Zip        _   Phone ___________          Fax _________

Email

Please bill my credit card    _____ Visa   _____ MasterCard   _____ Amex     _____ Discover

Credit Card # _______________________________           Amount _______       Exp. Date ______

Name as it appears on card ________________________________                  Security Code _____


   Please contact me about purchasing a table/tickets to the 2012 Signature Chefs Gala.


   Please fax or email completed form to Deandrea Dillard at (713) 964-5417, ddillard@marchofdimes.com. For
                   questions or information on attending the event, please call (713) 964-5415.

             Checks should be made payable to March of Dimes and sent to the Houston Division at:
          March of Dimes, Attention Deandrea Dillard, 3000 Weslayan, Suite 100, Houston, Texas 77027.

 All Fund the Mission contributions are 100% tax deductible and will be acknowledged with a receipt letter for tax
                 purposes. Fund the Mission contributions do not include admission to the event.

				
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posted:5/31/2012
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