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_______________

Signature__________________________________________________

 

Please fill in for our records only.

 

Name___________________________________Class_____________

Address__________________________________________________________

City____________________________ State __________ Zip_______________

Phone (_____)_____________ SS#____________________________________

Specialty____________________ e-mail address:________________________

Your Alumni Association receives no state support.

 

©