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 Participation Pledge Benefits: 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 Newsletter Acknowledgment on Foundation website Recognition in SAGES Mini-Scope e-newsletter Acknowledgment in Foundation Annual Report Complimentary tickets to select Foundation events Use of Donor’s Lounge at SAGES Meetings Legacy Benefactor pin Diamond Patron $10,000 Acknowledgment of participation as a Diamond Patron in Foundation Newsletter Acknowledgment on Foundation website Recognition in SAGES Mini-Scope e-newsletter Acknowledgment in Foundation Annual Report Complimentary tickets to select Foundation events Use of Donor’s Lounge at SAGES Meetings Diamond Patron Pin Benefactor $5,000 Acknowledgment of participation as a Benefactor in Foundation Newsletter Acknowledgment on Foundation website Recognition in SAGES Mini-Scope e-newsletter Acknowledgment in Foundation Annual Report Use of Donor’s Lounge at SAGES Meetings Benefactor Pin Donor $3,000 Acknowledgment of participation as a Donor in Foundation Newsletter Acknowledgment on Foundation website Recognition in SAGES Mini-Scope e-newsletter Acknowledgment in Foundation Annual Report Use of Donor’s Lounge at SAGES Meetings Friend $1,000 Acknowledgment of participation as a Friend in Foundation Newsletter Acknowledgment on Foundation website Acknowledgment in Foundation Annual Report Use of Donor’s Lounge at SAGES Meetings Supporter $500 Acknowledgment of participation as a Supporter in Foundation Newsletter Acknowledgment in Foundation Annual Report Pledge*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 NameFirstLastAddress*Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua 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.YemenZambiaZimbabweCountryPhone*Email*Notes to the SAGES FoundationIs there anything else you want to tell us? Please use the space above.Credit Card*American ExpressMasterCardVisaCard NumberMonth010203040506070809101112Year20142015201620172018201920202021202220232024202520262027202820292030203120322033Expiration Date Security CodeCardholder Name CommentsThis field is for validation purposes and should be left unchanged.