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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
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
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