Pledge Form

YES! I will help you fight Leukemia:
In recognition of the efforts of:

___________________________________________________
HPD Bicycle Relay Team Member

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I will be a sponsor at $__________________________________DATE_________________________
[] Patron Sponsorship ($100 - $174)
[] Bronze Sponsorship ($175 - $499)
[] Silver Sponsorship ($500 - $999)
[] Gold Sponsorship ($1000 - $4999)
[] Platinum Sponsorship ($5000 - UP)
[] Check Enclosed
[] Please do not send sponsor package so that
100% of my contribution is tax deductible		 [] Please Invoice Me

MAKE CHECKS PAYABLE TO
THE "LEUKEMIA SOCIETY".
Return pledge form and check to: HPD Bike Relay Team
P.O. Box 1788
Houston, Texas 77251-1788
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Name____________________________________________________

Firm_____________________________________________________

Address__________________________________________________

________________________________________________________

Phone___________________________________________________

_________________________________________________________
NAME ON CERTIFICATE
Jay R. Chase
Copyright © 1997 [Chase Family -Houston, TX USA]. All rights reserved.
Revised: March 02, 2003 .