Yes, I want to
support my Alma Mater!
LSU MEDICAL
ALUMNI ASSOCIATION
2020 Gravier St, Room 523, New Orleans, LA 70112
(504) 568-4009; e-mail address: ROAR@lsuhsc.edu
Check all appropriate boxes below and return form with
gift.
[Minimum suggested gift listed below.]
__ $50 for physicians who graduated before 2006
__ $25 for physicians who graduated in or after 2006
Additional contribution to support the following:
__ Center for Advanced Practice $_________
__ Scholarship Funds ( ___ merit, ___ need-based) $_________
__ Clinical Science Endowed Professorship Fund $_________
__ Basic Science Endowed Professorship Fund $_________
__ Area of greatest need $_________
Please send me information about
__ the Committee of 100---__ the 500
Club---__ Charitable Gift Annuity
__ Planned Giving---__ Gifts
of Appreciated Stock
For information about donations of appreciated stock or other
property, call Cathi Fontenot, MD, at (504) 568-4009.
__ Enclosed is a check for $__________ for 2011 support
(IMPORTANT: Please make your check payable
to LSU MEDICAL ALUMNI ASSOCIATION)
__ Charge $____________ to my credit card (see
below)
__ Visa __ MasterCard __ American Express
Card number_______________________________ Exp.
date_______________
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Signature__________________________________________________
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Please fill in for our records only.
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Name___________________________________Class_____________
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Address__________________________________________________________
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City____________________________ State __________
Zip_______________
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Phone (_____)_____________
SS#____________________________________
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Specialty____________________ e-mail address:________________________
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Your Alumni Association
receives no state support.
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