Contributions to the Plato Society at UCLA

Name                                                                                                                                                                                                                     

Address                                                                                                                                                                                                                                

City, State, Zip                                                                                                                                                                                                     

Day Phone                                                                                            Email                                                                                                      

Contribution Amount:         □   $250                                Your contribution is 100% tax-deductible.
□   $200You will receive a receipt for your tax-purposes.
□   $100
□   $50
□   $25
□  Other                               

Donation Payment Options: (please select one).  Each of the donation options will support the Plato Annual Fund (#54427).

□ My check is enclosed, made payable to UC Regents.

□ Please charge my              □ Master Card                      □ Visa                     □ American Express                             □ Discover

Card Number                                                                                                         Expiration Date                                                    

Signature                                                                                                                                                                                              

□ My company has a matching gift program.  Enclosed please find my matching gift form.

I am making my gift:  (optional)
□ As a holiday gift for                         □ In honor of                        □ In appreciation of                             □ In memory of    

We will mail a tribute card to the person you name below notifying him or her of your gift. The card will be sent within three days. It will not include the gift amount. If you do not wish to have a card sent, please indicate that here.

Person or occasion (include address):                                                                                                                                                            

Please return this form in the enclosed envelope or send directly to:

Jann Cripe, PLATO Society, UCLA Extension
1083 Gayley Avenue, Second Floor
Los Angeles, CA  90024
Phone (310) 794-0231   Fax (310) 794-0672
JCripe@unex.ucla.edu

Please see disclosure statements below.

Privacy Notice

The 1977 California Information Practices Act requires UCLA to inform individuals asked to supply information about themselves of the following: UCLA is requesting this information to update the general resource files of its External Affairs Department. Furnishing the information is strictly voluntary and will be maintained confidentially. The information may be used by other University departments in the regular course of business, but will not be disseminated to others except if required by law.
You have the right to review your own data file. Inquiries should be forwarded to the Assistant Vice Chancellor - Finance and Information Management, External Affairs, 10920 Wilshire Blvd., Suite 900, Los Angeles, CA 90024.

Donor's Consent to Use Personal Information

The University is grateful for the support it receives from alumni, parents, and friends. One of the ways we express our thanks is by listing the names of donors in web-based and/or print publications. Should you wish that your name not appear as a donor, please notify us if you have not already done so.

Fiduciary Responsibility of the UCLA Foundation

The UCLA Foundation is a California non-profit, public benefit corporation organized for the purpose of encouraging voluntary private gifts, trusts and bequests for the benefit of the UCLA campus. Responsibility for governance of the Foundation, including investments, is vested in its Board of Directors.

Recovery of Operating Costs from Private Gifts

As is customary with universities and other non-profit organizations across the country, a one-time gift fee is applied to all gifts to provide essential support necessary to UCLA's overall operation. The fee is currently 5%.
Effective 9/6/05

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