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 firstname.lastname@example.org. 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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