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ITT Campaign


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Member Letter of Intent

Note: fields marked with an * are required

Name: *
Institution:  *
Address: *    
Phone:  *
Email: *



  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): *

    Begining Date: *   
    *Payable over
    (select one): *

    (If other, please indicate)


  1. 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.

Year1st Qtr
(date & amount)
2nd Qtr
(date & amount)
3rd Qtr
(date & amount)
4th Qtr
(date & amount)
2012
Amount:


Amount:


Amount:


Amount:

2013
Amount:


Amount:


Amount:


Amount:

2014
Amount:


Amount:


Amount:


Amount:

2015
Amount:


Amount:


Amount:


Amount:

2016
Amount:


Amount:


Amount:


Amount:

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



  1. Please indicate how you would prefer your name to be listed for donor recognition purposes: *





  2. Additional Intructions:



  3. I would like to serve as a campaign volunteer by soliciting others


 *

Electronic Signature (please type full name): *

 

Date: *