Office of Development One
Phone: 212-404-3640
Please print this
form, fill in the required information and mail or fax it to the address above.
Please
note: A star (*) indicates a required field. Please make checks payable to
Donor information:
*Name: Title: (Dr. / Mr. / Mrs. / Ms.)
Company:
*Address:
*City: *State: *Zip:
Country (If outside the
*Phone:
E-Mail:
Gift Information:
(Please make Checks Payable to
* Enclosed is a gift of:
$25,000 ___ $10,000
___ $5,000 ___ $2,500 ___ $1,000
___ $500___ $250 ___ $100 ___
Other:
$_____________________
0 My
Employer, , will match my gift.
(Please attach your company’s matching gift form.)
Credit Card Information:
* Please charge my credit card:
0 MasterCard 0 American
Express 0 Visa
*Card Holders Name:
__________________________________________________
Account Number: *
Expiration Date: (month/year)
*Billing Address:
Street:
City:
State:
Zip:
Comments/Additional gift
information:
Please allocate my gift to
|
0 NYU
Cancer Institute |
0 Radiology
and Imaging |
|
0 NYU
Cardiac & Vascular Institute |
0 |
|
0 Rusk
Institute of Rehabilitation Medicine |
0 Faculty
and Friends Campaign |
|
0 NYU
Children’s Services |
0 General
Fund |
|
0 Other
___________________________ |
|
My/our gift is:
0 In honor
of
0 In memory
of
Please notify:
Please
fill in the section below if you would like us to notify family members or
those honored by your thoughtfulness. The amount of your gift will be
confidential.
Name:
Address:
City:
State:
Zip:
Relationship to deceased/honoree:
Additional Information:
Please
send me/us information on:
0 Making a
gift of securities.
0 Including
0 I have already included the
0 Please add me to your
mailing list.
If you have any questions or need any additional information, please contact the Office of Development by phone at 212-404-3640 or send an email to DevelopmentOffice@med.nyu.edu.