Fund Raiser 2023 Reservations and Donations | International College of Surgeons, US Section

Use this form to reserve tickets for the Fund Raiser in Chicago on September 7th or to make a donation if you are unable to attend. All donors (including those buying tickets for the event) will be listed on our website (www.ficsonline.org) acknowledging your support. Please indicate in the comments field if you wish to NOT be listed.

If you are planning to donate or order tickets for the fund raiser with a check, please complete this form and print it. All checks should be made payable to ICS-US Section and sent to 1524 N. Lake Shore Drive, Chicago, IL 60610.

Full Name of primary registrant / donor *

Street Address *

City *

State *

Zipcode *

Email *

Cell Phone Number *

The following options are available...

Patron: $200 per person
Provides entrance to the fundraiser, from 6:30-8:00pm and includes light hors d’oeuvres, beer, wine, and non-alcohol beverages. Guests will be able to tour the museum at their leisure.

Group Patron: $800 for 5 tickets
If you would like to bring friends, this option provides the same access as the Patron level with a discount for your group.

VIP Access: $500 per person
VIPs will gain early access to the event at 6:00pm. A special champagne cocktail and select hors d’oeuvres will be provided. A member of the museum staff will provide a Highlights of the Museum Tour for VIP guests. Finally, a souvenir to take home will be presented upon arrival.

Group VIP: $2,000 for 5 tickets
If you would like to bring friends, this option provides the same access as the VIP level with a discount for your group.

Indicate number of tickets in the appropriate category. Do not insert a dollar amount. Amount will be calculated in the total field.
Patron. @ $200

Group Patron @ $800

VIP Access @ $500

Group VIP @ $2000

If buying more than one ticket or using a group option please provide the names of your guests. This will be helpful if you do not all plan to arrive at the same time.

OTHER WAYS TO HELP

If you wish to make a donation in addition to your ticket(s) or if you cannot attend and wish to support the ICSUS and WSF with a major donation, your contribution will be used to support the work we do now and in the future. The following are examples of what and how much is needed.

Contributors at the $10,000 level will help us to purchase Anesthesia Machines.
Contributors at the $5,000 level will assist in the purchase of Electrosurgical Units.
Contributors at the $2,500 level will assist in the purchase of Portable Headlights.
Contributors at the $1,000 level will assist in the purchase of Cardiac, Oxygen and CO2 Monitors.

Enter your donation amount.

Please provide any additional information that might be helpful to properly apply your payment.

Attendance Verification
Please check this box if you plan to attend the event on September 7th in Chicago. Check this box even if you are "buying" tickets to confirm your intent to join us.

Total that will be charged to your credit card.

Payment Method

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Account Type

Checking

Savings

Routing Number

Account Number

Account Holder Type

Business

Personal

Business Name

Account Holder Name

By submitting payment, I am authorizing International College of Surgeons, US Section to initiate a single or recurring ACH/electronic debit in the amount indicated from the bank account I designated above. I understand that this Authorization will remain in full force and effect until the transaction is cancelled by me by contacting International College of Surgeons, US Section, or the ACH/electronic debit is processed from the designated account. I certify that (1) I am authorized to debit the bank account above and (2) the ACH/electronic payment I am authorizing complies with all applicable laws.

Name on Card

Card Number

Expiration

CSC

Billing Street

Billing Zip Code

Total Amount Due

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