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Support the cause through a Fund the Mission donation

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					                                           2013 Signature Chefs Gala
                                            Friday, October 25, 2013
                                           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: _____________________
PLEASE RESERVE:
_____ $50,000 Table for Twelve                                 _____ $10,000 Table for Ten

_____ $25,000 Table for Ten                                    _____ $5,000 Table for Ten

_____ $15,000 Table for Ten                                    ______ $3,500 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 2013 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 September 1, 2013.
Please charge my credit card ______                            Signature_________________________________________
Name on Card:____________________________________________________________________________________

Card Number:_________________________________Exp. Date_________________Security Code________

Address:___________________________________________________________________________________________

Phone: _________________________________________                                Fax:___________________________________

E-mail Address: ___________________________________________________________
Please fax or e-mail completed form to Katie Nixon at 713.964.5417 or mail to 3000 Weslayan, Suite 100, Houston, TX, 77027. For
additional information, contact March of Dimes at 713.623.2020 or knixon@marchofdimes.com. The deadline for inclusion of table
sponsors in the invitation is September 6, 2013. 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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posted:8/28/2013
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