DONOR’S NAME:______________________________________________________

ADDRESS:          _______________________________________________________

                    ________________________________________________________

E-Mail:                ________________________________________________________
 
Enclosed is my contribution:
(  )$15  (  )$25  (  )$50  (  )$100  (  )$_____________        

I wish to make a pledge of $1,000 as a:         
(to be paid over a 10 year period)                      

                                                                    

Enclosed is my $100 pledge payment for:
(  ) Golden Benefactor (  ) Double Golden Benefactor (  ) Sterling Benefactor  (  ) ______________         
 
I would like my contribution to be added to the endowment fund for
the following scholarship:  ________________________________________________
(Unless otherwise specified, all contributions are used by the General Fund to support
general philanthropies and operational expenses.)

This gift is in honor of____________________________________________ *

This gift is in memory of _________________________________________  *

*Please notify the following person of this gift:

________________________________________

________________________________________

________________________________________

(  ) Please send information about including the Foundation in my estate planning.


Sandra Wiese, Treasurer
Mu Phi Epsilon Foundation
9099 Regency Woods Drive
Kirtland, OH  44094-9380
rev. 1/19/05   
Send contribution to:
(  ) Golden Benefactor  (1st $1000)
(  ) Double Golden Benefactor (2nd $1000)
(  ) Sterling Benefactor (3rd $1000)
(  ) $4,000 or higher
MU PHI EPSILON FOUNDATION CONTRIBUTIONS