Institute for Molecular Manufacturing
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PLEASE PRINT and fax or mail this form to: Institute for Molecular Manufacturing 555 Bryant Street, Suite 354 Palo Alto, CA 94301 USA Tel: 650-917-1120 Fax: 650-917-1120 |
Yes, I want to join the nanotechnology
effort by becoming a Senior Associate. This donation is for a new membership continuing membership. renewal after fulfilling a 5-year pledge Send me the Senior Associate Letters and invite me to the annual gathering. My pledge is at the following level: |
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Associate | $250 annually for five years. | |||
Fellow | $500 annually for five years. Includes signed gift book. | |||
Colleague | $1000 annually for five years. Includes framed signed artwork. | |||
Friend | $5000 annually for five years. Includes engraved crystal "Friend of IMM" award on ebonite base and the signed framed artwork. | |||
This gift is an: | Individual contribution | Corporate contribution | ||
A matching gift will be made by my company |
Name: _______________________________________________
Address: ______________________________________________
City, State: ____________________________________________
Zip Code/Postal Code, Country: ___________________________
Phone: __________________________ Fax: __________________________
Email: _______________________________________________
My first annual donation is enclosed, payable to the Institute for Molecular
Manufacturing. IMM is a nonprofit foundation; donations are tax-deductible
in the U.S. to the full extent permitted by law. Donations can be made by
check from a U.S. bank, postal money order, VISA, or Mastercard. Credit
card donations may be sent by fax.
Name as it appears on credit card:_________________________________
VISA or Mastercard Number:_______________________
Expiration Date:_______________________
Signature _______________________________________
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Last updated 7October2000. The URL of this document is: http://www.imm.org/Application.html
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