Pledge Form SAGES Foundation Giving Levels:You may also download this form as a PDF file for contributions by check. All donations are welcome. Level of ParticipationPledgeBenefits:Legacy Benefactor$1,000.00 or more per year until retirement(This requires a 10 year commitment -Please contact the Foundation to set up)Acknowledgment of participation as a Legacy Benefactor in Foundation NewsletterAcknowledgment on Foundation websiteRecognition in SAGES Mini-Scope e-newsletterAcknowledgment in Foundation Annual ReportComplimentary tickets to select Foundation eventsUse of Donor’s Lounge at SAGES MeetingsLegacy Benefactor pinDiamond Patron$10,000Acknowledgment of participation as a Diamond Patron in Foundation NewsletterAcknowledgment on Foundation websiteRecognition in SAGES Mini-Scope e-newsletterAcknowledgment in Foundation Annual ReportComplimentary tickets to select Foundation eventsUse of Donor’s Lounge at SAGES MeetingsDiamond Patron PinBenefactor$5,000Acknowledgment of participation as a Benefactor in Foundation NewsletterAcknowledgment on Foundation websiteRecognition in SAGES Mini-Scope e-newsletterAcknowledgment in Foundation Annual ReportUse of Donor’s Lounge at SAGES MeetingsBenefactor PinDonor$3,000Acknowledgment of participation as a Donor in Foundation NewsletterAcknowledgment on Foundation websiteRecognition in SAGES Mini-Scope e-newsletterAcknowledgment in Foundation Annual ReportUse of Donor’s Lounge at SAGES MeetingsFriend$1,000Acknowledgment of participation as a Friend in Foundation NewsletterAcknowledgment on Foundation websiteAcknowledgment in Foundation Annual ReportUse of Donor’s Lounge at SAGES MeetingsSupporter$500Acknowledgment of participation as a Supporter in Foundation NewsletterAcknowledgment in Foundation Annual ReportPledge*Legacy BenefactorDiamond PatronBenefactorDonorFriendSupporterPlease choose a pledge level. All pledges (except Legacy Benefactor) are over 5 years and will have the first payment charged immediately with the remaining payments charged annually.If you wish to become a Legacy Benefactor, be invoiced in order to pay by check, or prefer to set up a custom pledge schedule, please contact the Foundation directlyDonor Name First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Notes to the SAGES FoundationIs there anything else you want to tell us? Please use the space above.Credit Card*American ExpressMasterCardVisa Card Number Month010203040506070809101112 Year20152016201720182019202020212022202320242025202620272028202920302031203220332034 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged.