check ______ cash ______ credit card (see form below)

I pledge my gift in the amount of $_________________________________ ______________ My company/I would like to be a $5,000 Event Sponsor ______________ My company/I would like to be a $2,500 Scholarship Sponsor

Payment type: _______ check

_______ cash

_______ credit card (see form below)

(Please make check payable to The Rotary Club of Los Angeles Foundation) Donor Name(s):_________________________________________________________________________________________________________ (PLEASE PRINT)

Address:_______________________________________________________________________________________________________________ City:_____________________________________________________State:________Zip:_______________Phone:_________________________ Email:_________________________________________________________________________________________________________________

Please charge my card for $__________________________________ Issued to:_____________________________________________________________ Card Type:

Visa

MasterCard

Amex

Discover

Card #:__________________________________________________________________Exp. Date______________Security Code_____________ Billing Address: same as above or ________________________________________________________________________________________ City:_____________________________________________________State:________Zip:_______________Phone:_________________________ Email:_________________________________________________________________________________________________________________ (For bank issued charge receipt)

Please present this form to a Rotary Club of Los Angeles Sergeant-at-arms or to the registration table, or email to [email protected], or mail to the Rotary Club of Los Angeles, 523 W. 6th Street, Suite 718, Los Angeles, CA, 90014

Your generous gift will be directed to the Rotary Club of Los Angeles Foundation’s Scholarship Fund