Note The minimum contribution to qualify for an AHAPAC

							                      Titan Club ..................................... $1,000 & up
                      Volunteer Club ............................. $500-$999
                      Capitol Club.................................. $250-$499
                      Chairman’s Club........................... $100-$249
                      VIP Club ....................................... $50-$99
                      Member ........................................ $10-$49

        Note: The minimum contribution to qualify for an AHAPAC club is $350.


Pledge Amount: $                                   will be paid by                   , 2010


Name:

Employer:


Credit Pledge to:   □ My Employer or Other:
Email Address:

Signature:


Note: As a PAC, Friends of THA is prohibited from accepting corporate donations. This
prohibition does not apply to LLCs or PLLCs.

You may return your completed pledge form by July 28, 2010 by any of the following
methods:

scrutchfield@tha.com

Fax: 615-242-4803

Suzette Crutchfield
Tennessee Hospital Association
500 Interstate Blvd., South
Nashville, TN 37210-4634