Please type your company name as you would like it to appear for recognition purposes in The Medical Center Foundation’s Hall of Honor located in the hospital’s North Patient Tower and all printed materials:

Company Name:

Representative’s Name:

Title: 

CEO’s Name:

Address:

City:       State:            ZIP:

Phone:                                                                 Fax:

Email Address:

I accept your invitation to join the Arbor Circle. Over a three year period, my company pledges $   for the improvement of our community health through the Arbor Circle. We would like to be recognized at the following level:

Signature Gifts: $100,000 or greater

Diamond Level: $50,000 - $99,999

Platinum Level: $30,000 - $49,999

Gold Level: $15,000 - $29,999

Silver Level: $7,500 - $14,999

Bronze Level: $4,500 - $7,499

Your pledge is payable over three years. Please indicate your payment schedule:

One-time payment of $ to be paid (month/year)

Semi-annual payment of $
       The Medical Center Foundation can expect to receive my semi-annual payment in the months of
     and .

Annual payments of $
       The Medical Center Foundation can expect to receive my annual payments in the month of  over the next
 
     one   two   three years.

Notes:

My typed name below serves as my signature:

             Date: