Company name:_________________________________________________________________________________________________________________________ Address:__________________________________________________________________________________________________________________________________ City/State/ZIP:___________________________________________________________________________________________________________________________ Contact person:___________________________________________________________________ Phone:______________________________________________
Yes! I/we would like to be a sponsor of the Mercy Foundation Jingle Mingle at the following level:
Corporate $2,500 and above Patron $1,500
Donor $1,000 Eight event tickets to the Jingle Mingle Two event tickets to the Jingle Mingle Two event tickets to the Jingle Mingle Tree of Hope cobblestone recognition Tree of Hope leaf recognition All donations will receive recognition in the Jingle Mingle program. Name as it is to appear in the program: ________________________________________________________________________________________________________________________________________________ I/we will support the event by: making a cash donation of $___________ or donating a silent auction item for the Jingle Mingle. Instructions/restrictions for silent auction item/gift certificate: ___________________________________
Description of gift(s) for silent auction booklet ________________________________________________________________________________________________________________________
Donation value of gift(s): $___________________
Please drop off silent auction items at the MercyCare Building (marketing department), 580 N. Washington St., Janesville or contact us at (608) 741-2422 to arrange pick-up. Additional event tickets can be purchased in advance at $45 each. Tickets will be $50 at the door. Please indicate the number of additional tickets desired: ________ PAYMENT METHOD Check—please make checks payable to Mercy Foundation Visa Mastercard AmEx Discover (Please fill in address and phone number above.) Card #_______________________________________________________________________ Exp. date _________________ CSV #______________ Signature ____________________________________________________________________ Print name___________________________________________________ Please kindly respond by November 18, 2015. You can call, fax or mail your donation commitment to: Mercy Foundation c/o Mercy Hospice Care Jingle Mingle 580 N Washington St., PO Box 1328 Janesville, WI 53548 Phone: (608) 741-2422 • Fax: (608) 743-2061
To comply with IRS rules and regulations, Mercy Foundation is a qualified 501(c)(3) organization. Nothing was received in exchange for this donation.
White: Mercy Foundation Yellow: Retain for donor tax record