DEPARTMENT OF NUTRITION SCIENCE
GIFT / PLEDGE FORM
DEPARTMENT OF NUTRITION SCIENCE
TOTAL GIFT/PLEDGE AMOUNT:
[ ] This gift will be matched.
Company: _________________________________
$ ____________________________
Please designate my gift as indicated below.
(Please obtain and complete matching gift form; mail to Purdue Foundation.)
$ ______ Nutrition Science 21st Century Fund
[51060161 4013004000]
$ ______ Ingestive Behavior Research Center
[51012883 4013004000]
$ ______ Women’s Global Health Institute
[51061271 4013004000]
$ ______ Nutrition and Exercise Research Center
[51012881 4013004000]
$ ______ Other
$ ______ NUTR Scholarship (see back for more scholarship options)
YOUR INFORMATION:
write in name of scholarship
Name: _________________________________
Spouse Name: __________________________
Address: _______________________________
Address: _______________________________
City: __________________ State: ___ Zip: ____
City: __________________ State: ___ Zip: ____
Telephone: _____________________________
Telephone: _____________________________
E-mail: ________________________________
E-mail: ________________________________
Alumna/us [ ] Yes
Alumna/us [ ] Yes
[ ] No
[ ] No
Major/Year: ____________________________
Major/Year: ____________________________
Name at Graduation: ____________________
Name at Graduation: ____________________
GIFT/PLEDGE PAYMENT INFORMATION:
[ ] Check (made payable to Purdue Foundation)
[ ] Pledge
I/we intend to make a total gift (excluding any anticipated matching gifts) of $ _________________
It is my/our desire to pay this pledge over a period of ________ years.
Please remind me/us: [ ] annually [ ] semi-annually [ ] quarterly [ ] monthly
Please send the first notice: _______________________________________________ (month/year)
Signature: ___________________________________
Date: ____________________________
[ ] Credit Card
I authorize Purdue University to charge $ ___________ to my:
[ ] Visa [ ] MasterCard [ ] Discover [ ] American Express
Card Number: ________________________________
Expiration Date: ___________________
Print name as it appears on card: ______________________________________________________
Signature: ___________________________________
Date: ____________________________
Please mail this form and your payment to:
HHS Office of Advancement, Room 106, 700 W. State Street, West Lafayette, IN 47907-2060
Questions? Call (800) 535-7303 or email [email protected].
THANK YOU!
EA/EOU 08.2014
NUTRITION SCIENCE SCHOLARSHIPS AND SUPPORT FUNDS
Undergraduate Scholarship Funds:
Undergraduate Scholarship Fund (General)
Scholarship for Foods and Nutrition (Dietetics)
Jane Walsh Andrews Scholarship (For in-state students)
Helen Clark Memorial Scholarship
Joan Krupinski Memorial Scholarship (For any student in former CFS departments)
Susan Ballard Lester Memorial Scholarship endowment
Sarah Cauble Johnson Foods and Nutrition Scholarship (for sophomore, junior or senior)
Berdine Martin Scholarship for Nutrition Science endowment (For in-state students)
Arthur and Cecelia Stuart Memorial Scholarship endowment (Dietetics, junior or senior)
Doris Harrell Thrasher Memorial Scholarship endowment
Thrasher Family Merit Scholarship Fund endowment
Olivia Bennett Wood Scholarship endowment
Graduate Student Support Funds:
Zoe E. Coulson Scholarship endowment
Evelyn Enrione Graduate Fellowship (For RD seeking Ph.D.)
Mary E. Fuqua Graduate Scholarship endowment (for Ph.D. students)
Graduate Student Travel Fund
Linda Okos Memorial Scholarship endowment
Richard Scholarship