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 Email Address Fax Number Origins Project (OP) Payment Amount Fair Market Value OP Premier Sponsor (one) 515,000 $ 6,520 OP Major Sponsor $10,000 $1,520 OP Circle Sponsor 55,000 $1,370 OP Leadership Sponsor $2,000 $1,015 Individual Ticket $150 $100 I would like to sponsor (check your selection) Premier $15 000 # of tickets Major circle Leadersh $10,000 _$5000 ip $2 000 Total Enclosed 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: [Mark one) Company Card_ Signature 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 All funds 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 of ASU are subject to foundation policies and fees. Due to the fair 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 of charitable contributions 30004641 EFTA_R1_02036923 EFTA02693367