EFTA02693367.pdf

Origins[ C T ARIZONA STATE UNIVERSITY ORIGINS PROJECT Sth Anniversary Gala Dinner Registration Form April 4, 2014 I 6:30pm I Desert Botanical Garden Gala Dinner Registration FORM Company Contact Name Address Daytime Phone Number Fax Number Email Address Origins Project (OP) OP Premier OP Major OP Circle OP Individual Sponsor (one) Sponsor Sponsor Leadership Ticket Sponsor Payment Amount 515,000 $10,000 55,000 $2,000 $150 Fair Market Value $ 6,520 $1,520 $1,370 $1,015 $100 # of tickets I would like to sponsor Premier Major circle Leadersh Total Enclosed (check your selection) $15 000 $10,000 _$5000 ip $2 000 Reserve Ticket(s) / seat(s) under the name of: Payment may be made by check or credit card. Please make checks payable to the MU FOUNDATION. J Check Enclosed 7 MasterCard 7 Visa 7 American Express J Discover Credit Card Number: Expiration Date: Name on Card: Signature [Mark one) Company Card_ Personal Credit Card Return form with Payment to Cynthia Schulze Email: [email protected] ASU Origins Project Phone: (480)965.0053 Old Main,Suite 105, 400 East Tyler Mall Fax: (480)965-0090 P.O. Box 871902, Tempe, AZ 85287-1902 Allfunds will be deposited with the ASU Foundation for A New American University, a separate nonprofit organization that exists to support Arizona State University (ASU). Gifts in support ofASU are subject to foundation policies andfees. Due to thefair market value of benefits received only payments in excess offer market value may be considered a charitable contribution. Please consult your tax advisor regarding the deductibility ofcharitable contributions 30004641 EFTA_R1_02036923 EFTA02693367