□ I wish to make a gift of $_____________.

□  Please bill me for my pledge of $___________ (minimum $2,500)
payable over  __ 1 year  __ 2 years  __ 3 years
to be billed  ___ Quarterly  ___ Biannually  ___ Annually ___
Other (describe)                                      

My/Our Name on the plaque should read                                                                      

My gift is in memory/honor of                                                                                          

I am employed by/retired from                                                                                       
                                                       
□ Please check if they participate in the Matching Gift Program.
□ I wish to remain anonymous

Special Recognition Gifts for Wall Plaque

Benefactor Patron Fellow Leadership Gold Circle Silver Circle Honor Roll

$10,000 and greater $7,500 - $9,999 $5,000 - $7,499 $2,500 - $4,999 $1,000 - $2,499 $500 - $999 $100 - $499

□    My check for $____________ is enclosed.  Checks should be made out to The University of Connecticut Foundation, Inc. (Please write “1957 Class Campaign” on the memo/note line.)

□    Please charge my credit card for the amount of $____________.     
___ Visa   ___ American Express   ___ Master Card   ___ Discover

Name as it appears on your card                                                                                     
Card Number _____________________  Expiration Date (month/year)             
*Code _________ (The last 3 or 4 digit number located on the back of card or on the front right for AMEX)