I would like to become a Benefactor of the Palmetto Gold Nurse Recognition and Scholarship Program.

My level of participation is specified below:

Platinum Sponsor ($15,000) - Complimentary full page ad in the Gala Program and up to 8 Gala Tickets

Gold Sponsor ($10,000) - Complimentary 1/2 page ad in the Gala Program and up to 6 Gala Tickets

Silver Sponsor ($7,500) - Complimentary 1/2 page ad in the Gala Program and up to 4 Gala Tickets

Bronze Sponsor ($5,000) Complimentary 1/2 page ad in the Gala Program and up to 2 Gala Tickets

Sponsor ($2,500) Complimentary 1/4 page ad in the Gala Program OR up to two Gala Tickets

Patron ($1,500)

Associate ($500)

Contributor ($250)

Supporter ($100)

Friend ($1 to $99.00) Specify amount

Other Amount

Benefactor First and Last Name

Name of Benefactor if Corporation/Business/Facility

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Benefactors will be recognized in the Palmetto Gold Gala Program Book. Please indicate how you wish your name to be listed

If contributing at the $2,500 level or above, please indicate the name of the individual and telephone/e-mail address to be contacted for complimentary information or contact Pi Johnson at pijohnson@bellsouth.net

If a corporate benefactor, please indicate tha name and address of the person to whom the tax receipt should be sent