New England Surgical Society Scholars Foundation Contribution Form Name: Address: City: State: Zip: Country: Telephone: Fax: E-Mail: I wish to make the following donation(s): Fund Amount General USD Fund (unrestricted) Centennial Fund USD Please consider a 100 USD donation in honor of the NESS’ Centennial! (unrestricted) Total USD PAYMENT INFORMATION: Please indicate your payment method below. CHECK (enclosed) For credit cards, complete the following: Amount Authorized: Name (as it appears on card): Credit Card #: Expiration Date: / Security Code: Your credit card’s security code a 3- or number located on the front or back of your credit card. Full Billing Address: Signature Block Signature: Fax this form with credit card information to (978) 524-0461, Your donation level is cumulative, determined by the sum total or make check payable to the New England Surgical Society of all your donations over time. and mail to: Scholar > $5,000 Surgical Society Samuel Jason Mixter Leader $2,500 ≥ 500 Cummings Center, Suite 4400 Nathan Sponsor $1,000 ≥ Beverly, Benefactor $500 ≥ Patron $100 ≥ Friend < $100 THANK YOU FOR YOUR CONTRIBUTION! The NESS Scholars Foundation is a 501(c)3 corporation organized to provide financial support to enhance the clinical and educational opportunities of the membership of the NESS in their efforts to strengthen the discipline of surgery in . The Scholars Foundation’s Federal Tax ID number is 02-0388641. Please retain this document for your records. It is an important document necessary for any available federal income tax deduction for this contribution. For additional information: Please contact the Foundation’s offices at the phone, fax, or e-mail below.
New England Surgical Society Scholars Foundation Contribution Form Name: Address: City: State: Zip: Country: Telephone: Fax: E-Mail: I wish to make the following donation(s): Fund Amount General Fund (unrestricted) USD Centennial Fund (unrestricted) Please consider a 100 USD donation in honor of the NESS’ Centennial! USD Total USD PAYMENT INFORMATION: Please indicate your payment method below. CHECK (enclosed) For credit cards, complete the following: Amount Authorized: Name (as it appears on card): Credit Card #: Expiration Date: / Security Code: Your credit card’s security code a 3- or number located on the front or back of your credit card. Full Billing Address: Signature: Signature Block Fax this form with credit card information to (978) 524-0461, or make check payable to the New England Surgical Society and mail to: Surgical Society 500 Cummings Center, Suite 4400 Beverly, Your donation level is cumulative, determined by the sum total of all your donations over time. Scholar > $5,000 Samuel Jason Mixter Leader ≥ $2,500 Nathan Sponsor ≥ $1,000 Benefactor ≥ $500 Patron ≥ $100 Friend < $100 THANK YOU FOR YOUR CONTRIBUTION! The NESS Scholars Foundation is a 501(c)3 corporation organized to provide financial support to enhance the clinical and educational opportunities of the membership of the NESS in their efforts to strengthen the discipline of surgery in . The Scholars Foundation’s Federal Tax ID number is 02-0388641. Please retain this document for your records. It is an important document necessary for any available federal income tax deduction for this contribution. For additional information: Please contact the Foundation’s offices at the phone, fax, or e-mail below.