Underwriting Commitment by MMIHouston


									                                     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 ddillard@marchofdimes.com. 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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