NU Origins — PROJECT ARIZONA STATE UNIVERSITY ORIGINS PROJECT 5th Anniversary Gala Dinner Registration Form April 4, 2014 I 6:30pm I Desert Botanical Garden Gala Dinner Registration FORM itsu Origins Company Contact Name Address Daytime Phone Number Fax Number Email Address Origins Project (OP) Payment Amount Fair Market Value OP Premier Sponsor (one) $25,000 $ 6,520 OP Major Sponsor $10,000 $1,520 OP Circle Sponsor $5,000 $1,370 OP Leadership Sponsor $2,000 $1,015 Individual Ticket $150 $95 I would like to sponsor (check your selection) Premier $25,000 ____Major circle Leadersh ___$10,000 __$5,000 _$2000 it of tickets Total Enclosed Reserve Ticket(s) / seat(s) under the name oh Payment may be made by check or credit card. Please make checks payable to the MU FOUNDATION. J Check Enclosed CI MasterCard U Visa J American Express CI Discover Credit Card Number: Expiration Date: Name on Card: Signature [Mark one] Company Card Personal Credit Card Return form with Payment to Cynthia Schulze MU Origins Project Old Main,Suite 105, 400 East Tyler Mall Box 871902, Tempe, AZ 85287-1902 Ali funds will be deposited with the ASU Foundation for A New American University, a separate nonprofit organization that exists to supportArizona State University (ASU). Gifts in support of ASU are subject to foundation policies and fees. Due to the fair market value of benefits received, onlypayments in excess of market value may be considered a charitable contribution. Please consult your tax advisor regarding the deductibility of charitable contributions 30004641 EFTA01205221