medicalcenterfoundation.com

The James H. Downey Society Membership Invitation:

Please print your name(s) 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:

Physician Name:

Physician & Spouse Name:

Address:

City:

State: Zip:

Phone:

Email address:

Birthdate:

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

One-time payment in Year One Year Two Year Three

Installation payments: Payment of $ Annually Semi-annually

Payment method:

Bill my credit card today for $

Send me a payment reminder notice later.

As a measure of my commitment, I hereby pronounce my intent, without in any way legally binding my heirs or myself, to contribute to The Medical Center Foundation:

$ (total pledge amount)

This pledge amount qualifies me for membership in THE JAMES H. DOWNEY SOCIETY (minimum eligibility for Downey Society is $3,000) as well as the following dual membership for myself and my spouse (please select one):

Signature Gifts	$100,000 or more over the next three years

The Laurel Society	$50,000 - $99,999 over the next three years (Platinum Leaf Level)
	$25,000 - $49,999 over the next three years (Gold Leaf Level)
	$10,000 - $24,999 over the next three years (Silver Leaf Level)

The Trellis Society	$3,000 - $9,999 over the next three years

Notes:

My typed name below serves as my signature:

Date: