2018 DONATION
FORM
2018 DONATION FORM
MARK ON MATHEMATICS IN 2018
MAKE YOUR MARK ON MATHEMATICS
FORM IN 2018
ABOUT CONTRIBUTION
YOU
YES,
TO
BE A
A PART
PART
OF MATHEMATICS!
MATHEMATICS!
YES, I I WANT
WANT
BE
OF
YES, TO
I WANT
TO SUPPORT
MATHEMATICS!
TITLE
£ PROFESSOR
£ DR.
£ MR.
ABOUT YOU
ABOUT
YOU
ABOUT YOU
MAILING ADDRESS
ABOUT YOU
TITLE
£ PROFESSOR
£ DR.
£ MRS.
FIRST NAME
TITLE
£ PROFESSOR
PROVINCE/STATE
TITLE
£ PROFESSOR
FIRST NAME
TITLE
£ PROFESSOR
FIRST NAME
PHONE
FIRST
NAME
MAILING
ADDRESS
£ MS.
OTHER ______________
LAST NAME
£ DR.
£ DR.
£ DR.
£ MR.
£ MR.
£ MRS.
£ MS.
OTHER ______________
£ MR.
£ MRS.
POSTAL/ZIP
CODE £
£ MR.
MRS.
£ MRS.
EMAIL
£ MS.
£ MS.
LAST
NAME OTHER ______________
£ MS.
OTHER ______________
COUNTRY
OTHER ______________
LAST NAME
LAST NAME
FIRST NAME
LAST NAME
MAILING
ADDRESS
£ I WOULD
LIKE
TO
BE
ADDED
TO
THE
FIELDS
INSTITUTE
EMAIL
LIST
TO
RECEIVE
INFORMATION ABOUT
UPCOMING EVENTS AND ANNOUNCEMENTS
MAILING
ADDRESS
PROVINCE/STATE
POSTAL/ZIP CODE
COUNTRY
MAILING ADDRESS
PROVINCE/STATE
PHONE
ACKNOWLEDGEMENT
OPTIONS
PROVINCE/STATE
PROVINCE/STATE
POSTAL/ZIP CODE
EMAIL
POSTAL/ZIP
CODE
POSTAL/ZIP
CODE
COUNTRY
COUNTRY
COUNTRY
£ I WOULD
LIKE TO
BE ADDED
TO THE ANONYMOUSLY
FIELDS INSTITUTE MAILING
EMAIL LIST TO RECEIVE INFORMATION ABOUT UPCOMING EVENTS AND ANNOUNCEMENTS
£ I PHONE
PREFER
TO MAKE
THIS
DONATION
PHONE
EMAIL
PHONE
EMAIL
I WOULD
LIKE
BE ADDED
ADDED
TO
THE
FIELDS
INSTITUTE
EMAIL
LIST
TO
RECEIVE
INFORMATION
ABOUT
UPCOMING
EVENTS
AND ANNOUNCEMENTS
ACKNOWLEDGEMENT
OPTIONS
£ I £
WOULD
LIKE
TO TO
DEDICATE
MY
DONATION
TO
RECOGNIZE
A LIST
MILESTONE,
CELEBRATE
A ABOUT
HOLIDAY,
OR
IN MEMORY
OF ANNOUNCEMENTS
SOMEONE
SPECIAL. PLEASE
I WOULD
LIKE
TO
BE
TO
THE
FIELDS
INSTITUTE
MAILING
TO TO
RECEIVE
INFORMATION
UPCOMING
EVENTS
AND
£ £
I WOULD
LIKE
TO
BE ADDED
TO
THE
FIELDS
INSTITUTE
EMAIL
LIST
RECEIVE
INFORMATION
ABOUT
UPCOMING
EVENTS
AND ANNOUNCEMENTS
WRITE THE DETAILS BELOW:
£ I PREFER TO MAKE THIS DONATION
ACKNOWLEDGEMENT
OPTIONS ANONYMOUSLY
ACKNOWLEDGEMENT OPTIONS
ACKNOWLEDGEMENT
OPTIONS
£
MAKE
THIS
DONATION
ANONYMOUSLY
£ I I PREFER
I WOULD TO
LIKE
TO DEDICATE
MY DONATION
IN RECOGNITION OF A MILESTONE, TO CELEBRATE A HOLIDAY, OR IN HONOR OF SOMEONE SPECIAL. PLEASE
£ £
PREFER
THIS DONATION
DONATION
ANONYMOUSLY
I PREFER TO
TO MAKE
MAKE THIS
ANONYMOUSLY
PROVIDE DETAILS BELOW:
£
LIKE TO
DEDICATE
MY DONATION
DONATION TO RECOGNIZE
RECOGNIZE A MILESTONE, CELEBRATE
CELEBRATE A A HOLIDAY,
HOLIDAY, OR IN IN MEMORY
MEMORY OF SOMEONE
SOMEONE
SPECIAL.
PLEASE
£ £ I I WOULD
WOULD
DEDICATE MY
MY
SPECIAL.
PLEASE
I WOULD LIKE
LIKE TO
TO DEDICATE
DONATION IN TO
RECOGNITION OF A A MILESTONE,
MILESTONE, TO CELEBRATE
A HOLIDAY, OR
OR IN HONOR OF OF
SOMEONE SPECIAL.
PLEASE
WRITE
THE
DETAILS
BELOW:
WRITE
THE DETAILS
DETAILS
BELOW:
PROVIDE
BELOW:
DONATION DETAILS
DONATION DETAILS
£ $2,000
£ $1,000
DONATION
DETAILS
DONATION
DETAILS
I WOULD LIKE
TO GIVE:
£ $2,000
£ $1,000 £ $500 £ $200 £ $100 OTHER _________
I WOULD LIKE TO GIVE: £ $500 £ $200 £ $100 OTHER _________
I WOULD LIKE TO GIVE:
PAYMENT METHODS
£ $2,000
£ $1,000
£ $500
£ $200
PAYMENT
METHODS
• ONLINE:
FIELDS.UTORONTO.CA/ABOUT/FUNDRAISING
I I WOULD
£ $2,000
$2,000
£ $1,000
$1,000
£ $500
$500
£ $200
$200
WOULD LIKE
LIKE TO
TO GIVE:
GIVE:
£
£
£
£
• CHEQUE/MONEY
ORDER: PAYABLE
TO
“THE ORDER*
FIELDS INSTITUTE” £ VISA
£
CHEQUE*
£
MONEY
PAYMENT METHODS
PAYMENT
METHODS
PAYMENT
• CREDIT
CARD
(COMPLETE DETAILS BELOW)
* PLEASE MAKE PAYABLE TO “THE FIELDS INSTITUTE”
£
CHEQUE*
£
MONEY ORDER*
£
• • ONLINE:
ONLINE: FIELDS.UTORONTO.CA/ABOUT/FUNDRAISING
FIELDS.UTORONTO.CA/ABOUT/FUNDRAISING
£ $100
$100
£ £ $100
VISA
OTHER _________
OTHER _________
_________
OTHER
£ MASTERCARD £ AMEX
£ MASTERCARD £ AMEX
* PLEASE MAKE PAYABLE TO “THE FIELDS INSTITUTE”
£ VISA
MASTERCARD
£ AMEX
• • CHEQUE/MONEY
ORDER:
PAYABLE
TO
“THE
FIELDS INSTITUTE”
INSTITUTE”
CARDHOLDER
NAME
(AS IT £
APPEARS
ON
THE
CARD)
CHEQUE/MONEY
PAYABLE
TO
“THE
FIELDS
• • CREDIT
DETAILS
BELOW)
CREDIT CARD
CARD
DETAILS
BELOW)
MASTER
CARD
/ (COMPLETE
VISA / AMERICAN
EXPRESS
(CIRCLE
ONE) & NUMBER
CARDHOLDER’S
NAME
ON
THE
CARD)
CARDHOLDER
NAME (AS
(AS IT
IT APPEARS
APPEARS ON
THE
CARD)
EXPIRY DATE
CCV OR CVC NUMBER
CREDIT
CARD CARD
NUMBER
/ VISA / AMERICAN
EXPRESS (CIRCLE ONE) & NUMBER
£ MASTER
VISA
£ MASTERCARD
£
£
VISA
MASTERCARD
£ AMEX
AMEX
EXPIRY
EXPIRY
DATE DATE NAME (AS IT APPEARS
CARDHOLDER’S
CARDHOLDER’S
APPEARS ON
ON THE
THE CARD)
CARD)
SIGNATURE
DATE
CCV OR
CCV CVC
OR NUMBER
CVC NUMBER
SIGNATURE
SIGNATURE
CREDIT
CARD
OPTIONS
FOR
SUPPORT (SELECT ONE)
CREDIT
CARD
NUMBER DATE
£ THE DATE
INSTITUTE’S GREATEST NEEDS
EXPIRY
EXPIRY
DATE
OPTIONS
FOR SUPPORT (SELECT ONE)
SUPPORT OPTIONS (SELECT ONE)
SIGNATURE
SIGNATURE
£ THE INSTITUTE’S GREATEST NEEDS
DATE
£ MATHEMATICS OUTREACH
CCV OR AND
CVC EDUCATION
NUMBER
CCV OR CVC NUMBER
£ MATHEMATICS
SCIENTIFIC PROGRAMMING
AND EDUCATION
EVENTS
DATE
DATE AND
£
OUTREACH
£ FIELDS MEDAL SYMPOSIUM £ UNDERGRADUATE SUMMER RESEARCH PROGRAM
£ PUBLIC
LECTURES
SUPPORT
OPTIONS (SELECT
(SELECT ONE)
SUPPORT
OPTIONS
ONE) £ GRADUATE STUDENTS AND POST DOCS
£ SCIENTIFIC PROGRAMMING AND EVENTS
£ FIELDS MEDAL SYMPOSIUM
£ FIELDS MEDAL SYMPOSIUM
£ SCIENTIFIC PROGRAMMING
£ OUTREACH AND K-12 EDUCATION
THANK YOU FOR SUPPORTING THE FIELDS INSTITUTE
THANK
YOU
THE FIELDS
FIELDS INSTITUTE
INSTITUTE
THANK
YOU FOR
FOR SUPPORTING
SUPPORTING THE
TAX-DEDUCTIBLE
RECEIPTS WILL
BE ISSUED
TO ALL CANADIAN RESIDENTS. PLEASE
ALLOW FIELDS
FOR A THREE WEEK
TURNAROUND TIME.
THANK
YOU
FOR
SUPPORTING
THE
INSTITUTE
SUPPORTING
THE
FIELDS
INSTITUTE
£ FIELDS
FIELDS MEDAL
MEDAL SYMPOSIUM
SYMPOSIUM
£ £
£ UNDERGRADUATE
UNDERGRADUATE SUMMER
SUMMER RESEARCH
RESEARCH PROGRAM
PROGRAM £ £ SCIENTIFIC
PROGRAMMING
SCIENTIFIC
PROGRAMMING
£ PUBLIC
PUBLIC LECTURES
LECTURES
£ £
£ GRADUATE
GRADUATE STUDENTS
STUDENTS AND
AND POST
POST DOCS
DOCS £ £ OUTREACH
AND
K-12
EDUCATION
OUTREACH
AND
K-12
EDUCATION
TAX-DEDUCTIBLE RECEIPTS WILL BE ISSUED TO ALL CANADIAN RESIDENTS. PLEASE ALLOW FOR A THREE WEEK TURNAROUND TIME.
NON-ANONYMOUS DONOURS WILL BE ACKNOWLEDGED BY NAME IN THE INSTITUTE’S NEWSLETTER AND ANNUAL REPORT.
THE FIELDS INSTITUTE HAS A STRICT PRIVACY POLICY. ALL DONOR INFORMATION IS CONFIDENTIAL AND WILL NOT BE DISTRIBUTED TO EXTERNAL ORGANIZATIONS
TAX-DEDUCTIBLE RECEIPTS WILL BE ISSUED TO ALL CANADIAN RESIDENTS. PLEASE ALLOW FOR A THREE WEEK TURNAROUND TIME.
NON-ANONYMOUS DONOURS WILL BE ACKNOWLEDGED BY NAME IN THE INSTITUTE’S NEWSLETTER AND ANNUAL REPORT.
THE FIELDS INSTITUTE FOR RESEARCH IN MATHEMATICAL SCIENCES
NON-ANONYMOUS
WILL
BE ALL
ACKNOWLEDGED
BY
NAME IN THE
INSTITUTE’S
NEWSLETTER/ANNUAL
REPORT
THE
FIELDS INSTITUTE HAS A DONOURS
STRICT
POLICY.
DONOR
INFORMATION
IS CONFIDENTIAL
WILL NOT BE DISTRIBUTED
TO EXTERNAL ORGANIZATIONS
222 PRIVACY
COLLEGE
ST. | TORONTO
| ONTARIO
| CANADA
| M5T 3J1 | AND
WWW.FIELDS.UTORONTO.CA
THE FIELDS INSTITUTE HAS A STRICT PRIVACY POLICY: ALL DONOR INFORMATION IS CONFIDENTIAL AND WILL NOT BE SHARED WITH OTHER ORGANIZATIONS.
TAX-DEDUCTIBLE RECEIPTS
TO
CANADIAN
RESIDENTS.
PLEASE
FOR
TIME.
THE FIELDS
INSTITUTE
FOR RESEARCH
IN MATHEMATICAL
SCIENCES
TAX-DEDUCTIBLE
RECEIPTS WILL
WILL BE
BE ISSUED
ISSUED
TO ALL
ALL
CANADIAN
RESIDENTS.
PLEASE ALLOW
ALLOW
FOR A A THREE
THREE WEEK
WEEK TURNAROUND
TURNAROUND
TIME.
222 COLLEGE
ST. | BE
TORONTO
| ONTARIO | CANADA
| M5T
3J1
| WWW.FIELDS.UTORONTO.CA
NON-ANONYMOUS DONOURS
WILL
ACKNOWLEDGED
BY
NAME
IN
THE
INSTITUTE’S
NEWSLETTER/ANNUAL
REPORT
THE FIELDS
INSTITUTE
FOR RESEARCH
IN MATHEMATICAL
SCIENCES
NON-ANONYMOUS DONOURS
WILL
BE ACKNOWLEDGED
BY NAME
IN THE INSTITUTE’S
NEWSLETTER/ANNUAL REPORT
THE FIELDS INSTITUTE
HAS
A STRICT
PRIVACY
POLICY:
ALL TORONTO
DONOR INFORMATION
AND
NOT BE SHARED WITH OTHER ORGANIZATIONS.
222 HAS
COLLEGE
STREET,
2ND
FLOOR|
| ONTARIO IS IS
| CONFIDENTIAL
CANADA
| M5T
3J1 WILL
| WWW.FIELDS.UTORONTO.CA
THE FIELDS INSTITUTE
A STRICT
PRIVACY
POLICY:
ALL DONOR INFORMATION
CONFIDENTIAL
AND
WILL
NOT BE SHARED WITH OTHER ORGANIZATIONS.
THE FIELDS INSTITUTE FOR RESEARCH IN MATHEMATICAL SCIENCES
THE FIELDS INSTITUTE FOR RESEARCH IN MATHEMATICAL SCIENCES
222 COLLEGE STREET, 2ND FLOOR| TORONTO | ONTARIO | CANADA | M5T 3J1 | WWW.FIELDS.UTORONTO.CA
222 COLLEGE STREET, 2ND FLOOR| TORONTO | ONTARIO | CANADA | M5T 3J1 | WWW.FIELDS.UTORONTO.CA