Sustaining Partners Program

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SUSTAINING PARTNERS PROGRAM Philanthropic Investment Agreement Please complete all sections of the agreement and return it with your contribution. Organization name: Contact name: Title: Mailing address: Phone: (W) (C) Email: For recognition purposes, please indicate exactly how you would like your name to appear: Check here if you would prefer to remain anonymous. Please choose your level of support. Sustaining Partnership $7,500 contribution $2,500 contribution $5,000 contribution $1,000 contribution Please designate your gift commitment: $___________ MedStar Health: Area of greatest need $___________ MedStar National Rehabilitation Hospital $___________ MedStar Franklin Square Medical Center $___________ MedStar Patient Safety Institute $___________ MedStar Georgetown University Hospital $___________ MedStar Southern Maryland Hospital Center $___________ MedStar Good Samaritan Hospital $___________ MedStar St. Mary’s Hospital $___________ MedStar Harbor Hospital $___________ MedStar Union Memorial Hospital $___________ MedStar Health Research Institute $___________ MedStar Visiting Nurse Association $___________ MedStar Institute for Innovation $___________ MedStar Washington Hospital Center $___________ MedStar Montgomery Medical Center (continued on next page) Philanthropic Investment Agreement Our organization will fulfill this corporate partnership commitment as follows: CHECK: Please make checks payable to: MedStar Health (Note the Sustaining Partners Program) CREDIT CARD: * Visa * MasterCard * American Express * Discover *You may also give securely online at MedStarHealth.org/SustainingPartners. Name on the card: Credit card #: Expiration Date: / For a contribution of $ CID#: Address of card holder, including ZIP code: INVOICE: Invoice instructions: Thank you for your partnership with MedStar Health. We will provide a receipt for tax purposes after an annual contribution payment has been made. Signature Date Signature – MedStar Philanthropy Date We will provide you with a copy of the signed Philanthropic Investment Agreement. Please return to: Megan Long, Manager, Sustained Giving MedStar Health Philanthropy 5565 Sterrett Place, Fourth Floor Columbia, MD 21044 410-772-6670 PHONE [email protected] EMAIL Note: Contributions are graciously accepted for charitable purposes that intend to promote better health care, benefit society and/or demonstrate good corporate citizenship. Donations may not be linked, implicitly or explicitly, to any expectation or agreement that MedStar Health will use, order, recommend, or make a referral for any product or service and may not result in a personal benefit to any individual, corporation, foundation, or organization. SUSTAINING PARTNERS PROGRAM 14-MHP-0950.042014.

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