9 TH ANNUAL RX MIXER BENEFITING THE IACP FOUNDATION SUNDAY, JUNE 2, 2013 ~ 6:30 P.M. – MIDNIGHT SPONSORSHIP AND AUCTION ITEM COMMITMENT FORM Company __________________________________________________________________________________________________________ Contact Name ____________________________________________________________________Title ________________________________ Address ____________________________________________________________________________________________________________ City ____________________________________ State__________________________________ Zip ________________________________ Phone __________________________________ E-mail ________________________________ Web Site ____________________________ __________________________________________________________________________________________________________________ Please indicate how your name should appear on all sponsorship recognition. Limited Availability: To reserve your spot, please mark (“X”) for the sponsorship(s) you desire. PREMIUM SPONSORSHIP CASINO SPONSORSHIP TABLE SPONSORSHIP – $1,750 (TABLE OF EIGHT) ____ $10,000 Auction Sponsor – SOLD ____ $5,000 Roulette Table Sponsor _____________ # of Tables (one available) $ ____________ Table subtotal ____ $10,000 Funkadelic Entertainment Sponsor – SOLD ____ $3,000 Blackjack Table INDIVIDUAL TICKETS – $150 Sponsor (seven available) _____________ # of Tickets ____ $8,000 Disco Den Sponsor – SOLD Total ticket amount ____ $3,000 Texas Hold ‘em ____ $8,000 Far Out T-shirt Sponsor – SOLD Table Sponsor (one available) PAYMENT CALCULATION ____ $6,500 Table Decor Sponsor – SOLD ____ $3,000 Craps Table Sponsor (two available) $ ____________ Sponsorship subtotal $ ____________ Cash Donation subtotal ____ $5,000 Photo Booth Sponsor – SOLD ____ $2,000 Casino Fun Bucks Sponsor – SOLD $ ____________ Table Sponsorship subtotal $ ____________ Ticket Sales subtotal ____ $5,000 Bar Sponsor – SOLD $ ____________ Total Due IACP Foundation q I/We cannot attend the Rx Mixer but would like to donate to the Auction. Please have an auction committee member give me a call! q I/We cannot attend the Rx Mixer but would like to support the IACP Foundation with a donation of $ ______________________. PLEASE RESPOND BY February 1, 2013 IN ORDER TO MEET PRINT DEADLINES. Payment q Check (Please make payable to IACP Foundation.) q Credit Card (circle one): Discover VISA MasterCard AMEX Credit Card Number_______________________________________Exp. Date ______________________V-code ___________________________ Card Holder’s Name____________________________________________________________________________________________________ Billing Address of Card _________________________________________________________________________________ (if different from above) Authorized Signature ___________________________________________________________________________________________________ Person filling out this form (if different from above)_______________________________________________________________________________ Please mail or fax a copy to: IACP Foundation Phone: (281) 933-8400 Attn: Rx Mixer Fax: (281) 495-0602 4638 Riverstone E-mail: meridyth@iacprx.org Missouri City, TX 77459 Your contribution to IACP Foundation is tax-deductible to the extent permitted by law. IACP Foundation is a 501(c)(3) non-profit, charitable organization. Tax I.D. #90-0064139. In compliance with the Internal Revenue Service guidelines, all donations (minus fair market value) are tax-deductible. We estimate the fair market value of each ticket to be $120.00 per person. The amount of your contribution that is deductible for federal income tax purposes is the difference between the cash donation given and the value of the benefits received. Please retain a copy for your tax records. 7 ©2012 International Academy of Compounding Pharmacists (IACP). All rights reserved.
IACP RX Mixer
To see the actual publication please follow the link above