UW Medicine

Name_________________________________________________________________

Address______________________________________________________________

Phone_____________________________ Email______________________________

ENCLOSED IS MY/OUR GIFT (OR INITIAL PLEDGE PAYMENT) OF:
__$500 __$250 __$100 __$50 __$25 __Other__________

__ I/we prefer to make a multi-year pledge of $_____________ per year for a total of $______.

Please send reminders: __Monthly __Quarterly __Semi-annually payments of $____.

PLEASE DESIGNATE THIS GIFT/PLEDGE TO:
__Anesthesiology General Gifts (NEURSC) - To support "Neuroscience for Kids", created by Eric H. Chudler, Ph.D.

PAYMENT INFORMATION:
__Enclosed is my/our check made payable to the University of Washington Foundation.
__I/we prefer to pay by credit card.
Please charge: __MasterCard __Visa __American Express

Account number:___________________ Expiration Date:__________________

Specify full name as it appears on card:_______________________________

Signature (necessary to validate payment):______________________________

__Enclosed is a completed matching gift form from my or my spouse's employer.

PLEASE SEND INFORMATION ON:
__Gifts that provide life income.
__Including UW Medicine in my/our will.

If you have any questions, please call UW Medicine Development at 206-543-5686.

Please return all gifts to:

UW Medicine Development
Box 358045
University of Washington
Seattle, WA 98195-8045
X3AKU
Your gift is tax deductible as specified in IRS regulations. Pursuant to RCW 19.09, the University of Washington is registered as a charitable organization with the secretary of state, state of Washington. For information, call the Office of the Secretary of State, 1-800-332-4483.