SUPER DONOR PERIODIC TABLE
PLEDGE FORM
Name(s)
Address ________________________________ City _________________ State _____ ZIP
Home phone ____________________________ Home e-mail
Business phone __________________________ Business e-mail
Element Costs:
 Purple elements in periods 1-3 are $500
 Pink elements in period 4 are $1,000
 Blue elements in period 5 are $1,500
 Green elements in period 6 are $2,000
 Tan elements in period 7 are $2,500
 Gold elements in periods 1-7 are $5,000
 In the insert for lanthanide and actinide series (purple), all lanthanides are $300 and actinides $400, with the
Gold elements of U and Pu at $4,500
PLEASE NOTE: The purchasing of elements will be on a first-come basis. If your element of choice has
already been purchased – we will notify you immediately. Please visit our website at
www.uwsuper.edu/give2uws/super-donor-periodic-table.cfm to see a complete list of elements, pricing, and
current availability.
I/We agree to provide support to the UW-Superior Foundation for the Chemistry Department
Super Donor Periodic Table – with the following gift(s):
Element/Particle 1: ______________ [ ] equipment [ ] scholarship
Element/Particle 2: ______________ [ ] equipment [ ] scholarship
$
$
TOTAL:
$
Please list my name as follows: _______________________________________________________________
Comments: _______________________________________________________________________________
Payment Options
[ ] Check enclosed and payable to UW-Superior Foundation
[ ] Credit card [ ] VISA [ ] MasterCard [ ] Discover
[ ] American Express
Name as it appears on card
Card Number _______-_______-_______-_______ Expiration ____________ Security Code ________
Signature(s)
Date
Thank you! Your gift is tax deductible to the extent of the law.