Annual Gala Sponsorship Form Name(Required) First Last Company NameAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Select Your Sponsorship Level(Required)Select Sponsorship Level BelowTitle Sponsor ($20,000)Platinum Sponsor ($10,000)Gold Sponsor ($7,500)Silver Sponsor ($5,000)Bronze Sponsor ($2,500)Supporter ($1,000)Please note that this form is for sponsorship payments only, not to purchase individual tickets or tables. Provide Your Credit Card Information (Secure Transaction) DiscoverMasterCardVisaSupported Credit Cards: Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name Total
