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Underwriting Commitment


									                                     Thursday, October 18, 2012
                                      Hilton Americas - Houston
                                 UNDERWRITING COMMITMENT FORM
Please print (or type) name exactly as you wish it to appear in printed materials

Contact Name:________________________________________________________________________________________

Address: ______________________________________________________________________________________________

City: ____________________________                              State: ______________           Zip Code: _____________________
_____ $50,000 Fiery Cayenne Table for Twelve                               _____ $10,000 Sassy Saffron Table for Ten

_____ $25,000 Hot Chili Table for Ten                                      _____ $5,000 Snappy Cinnamon Table for Ten

_____ $15,000 Rockin Rosemary Table for Ten                                _____ $3,500 Sizzling Serrano Table for
                                                                                                                      Ten (limited)
_____ I/We would like to make a donation to“FUND THE MISSION” in the amount of
_____ $10,000 _____ $5,000_______ $2,500______ $1,000 _______ $500 _____ $250 _____ other
In honor of _____________________________ for the 2012 Signature Chefs Gala

*** If you are splitting the cost of the table with others, please enclose a list of names,
phone numbers, and amounts each will pay.
*** Table placement will be made based on sponsorship level and date of commitment.

Please make checks payable to MARCH OF DIMES or check here _____ if you would like to
be invoiced August 1, 2012.
Please charge my credit card ______                             Signature_________________________________________
Name on Card:____________________________________________________________________________________

Card Number:_________________________________Exp. Date_________________Security Code________


Phone: _________________________________________                                 Fax:___________________________________

E-mail Address: ___________________________________________________________
Please fax or e-mail completed form to Deon Dillard at 713.964.5417 or mail to 3000 Weslayan, Suite 100, Houston, TX, 77027. For
additional information, contact Deon Dillard at 713.964.5415 or The deadline for inclusion of table
sponsors in the invitation is July 15, 2012. For IRS purposes, the fair market value of each seat is $60. Contributions will be acknowledged
with a receipt letter for tax purposes.

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