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: Cynthia.schulze@asu.edu
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
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