Franz Alexander Society
Name
*
First Name
Last Name
Institute Affiliation (check all that apply)
*
Alumni
Current Faculty
Former Faculty
Student
Friend(s) of the Institute
Other
If "Other", please explain
Date of Birth
*
-
Month
-
Day
Year
Date
Spouse/Partner Name
First Name
Last Name
Spouse/Partner Institute Affiliation (check all that apply)
Alumni
Current Faculty
Former Faculty
Student
Friend(s) of the Institute
Other
If "Other", please explain
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I have provided/would like to provide for the Institute in the following way:
*
Bequest to the Institute in my living will or trust
Name the Institute as a beneficiary of a retirement account
Name the Institute as a beneficiary of an insurance policy
Name the Institute as a beneficiary of an outside trust arrangement
Other
If "Other", please explain
My Gift is
*
Unrestricted
Designated
If "Designated", what would you like your gift to go towards?
What are your Acknowledgement preferences?
*
Please include my (and if applicable, my spouse/partner’s) name on the annual report
I/We are honored to be part of the Franz Alexander Society but prefer to remain anonymous
If you would like to be recognized on the Annual Report, please indicate how you would like your name(s) listed
Personal stories such as yours often inspire others to give. May we contact you about being quoted or profiled in a coming newsletter or publication?
*
Yes
No
Signature
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