Support the cause through a Fund the Mission donation by MMIHouston


									                             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.


Individual Contact


City ___________     State        Zip       _    Phone ___________         Fax _________


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, 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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