Member Letter of Intent

Note: fields marked with an * are required

1. This pledge is intended to provide a TOTAL GIFT of   *    to the American Society for Gastrointestinal Endoscopy Foundation in support of the Institute for Training & Technology Capital Campaign.
   
   
2. The balance of this pledge commitment will be paid according to the following schedule (please check one): *
   ANNUALLYSEMI-ANNUALLYQUARTERLY
   

   Begining Date: *
   *Payable over (select one): *	FIVE YEARS OTHER
   (If other, please indicate)

3. Please complete payment schedule chart to ensure reminder notices are sent on time.  *

Please select a date and specify an amount for each year and quarter that applies.

Invoices will be mailed to you. Payments may be made by credit card online or by mailing a check payable to ASGE.

4. Please indicate how you would prefer your name to be listed for donor recognition purposes: *
   
   
   
   I would like to be anonymous
   
   
5. Additional Intructions:
   
   
   
   
6. I would like to serve as a campaign volunteer by soliciting others
   YESNO

 * I have carefully read and completed this letter of intent form myself, and provided current and accurate information to the best of my ability. I understand that typing my name below serves as an electronic signature for purposes of this form.

Electronic Signature (please type full name): *

 

Date: *