Gala Sponsorship Form
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YES, I would like to support Memorial Hospital Los Banos Foundation’s 2011 Annual Gala Magical FantaSea.
Please print and return this form to: Memorial Hospital Los Banos Foundation
Attn: Michelle Marchese, Philanthropy Coordinator
520 West I Street, Los Banos, CA 93635
Thank you for your kind generosity!
[ ] SPONSORSHIP
I would like to sponsor at this level:
[ ] Gold $10,000
[ ] Silver $5,000
[ ] Bronze $1,000
[ ] Friends of the Hospital $500
[ ] AUCTION ITEM DONATION
I would like to donate item(s) to the silent/live auction:
Item 1 Description:
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Value: $ __________________
Item 2 Description:
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Value: $ __________________
[ ] PROGRAM BOOK ADVERTISEMENT
I would like to advertise in the program book: (8 ½ x 11)
[ ] Full-page Advertisement, $500
[ ] Quarter-page Advertisement, $200
[ ] Half-page Advertisement, $300
[ ] Business Card Advertisement, $35
[ ] SPONSOR/DONOR INFORMATION
Company:
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___________________________________________________________
Address:
___________________________________________________________
___________________________________________________________
___________________________________________________________
Phone: _____________________
E-mail:_________________________________________________
[ ] I CANNOT ATTEND THE GALA
I would like to make a cash donation in the
amount of $_________________________.
PAYMENT INFORMATION
[ ] I am enclosing a check or money order (made payable to MHLB Foundation)
[ ] Please charge the following credit card in the total amount of $________________________
Name on Card:
_________________________________________________
Corresponding Address Address:
___________________________________________________________
___________________________________________________________
___________________________________________________________
Card Number: _________________________________
Exp Date: __________ Security Code: _______
Signature:________________________________________________________