Pledge Sheet

Division of Urologic Surgery
Attn John Hartwick
2113 Physicians Office Bldg CB 7235
170 Manning Dr
Chapel Hill NC 27599-7235

Name(s)

___________________________________

Address

___________________________________

City, State, Zip

___________________________________

Preferred Phone

___________________________________

E-mail

___________________________________

I'm proud to make a gift or pledge of:

¤  $500                     ¤  $50

¤  $250                     ¤  Other $______

¤  $100

Please indicate how you designate your gift:

¤  Urology General Fund     ¤  Urologic Research     ¤  Residency Program Education

May we list your name(s) in our publications?
¤  Yes              ¤  No

If yes, how would you like your name(s) to appear?

________________________________________

If this is a commemorative gift, please indicate:
¤ in memory of                          ¤ in honor of

Name

________________________________________

Occasion

________________________________________

Please notify (Name)

________________________________________

Address or E-mail

________________________________________

We sincerely appreciate your gift.  All gifts, large or small, contribute to
the advancement of urologic medicine and promote
the highest standard of care for every patient.

Contributions are tax deductible as
provided by law.

Please tell us where you found this card:
¤ newsletter   ¤ other __________________

Additional Comments

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__________________________________________________

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