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Fund the Mission Commitment Form Sponsored by Cigna 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 2013 Signature Chefs Gala. Please fax or email completed form to Amanda Hance at (713) 964-5417, firstname.lastname@example.org. For questions or information on attending the event, please call (713) 623-2020. Checks should be made payable to March of Dimes and sent to the Houston Division at: March of Dimes, Attention Amanda Hance, 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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