2018 DONATION
FORM
MARK ON MATHEMATICS IN 2018
MAKE
YOUR
MARK
ON MATHEMATICS
MAKE
YOUR
MARK
ON MATHEMATICS
IN
2018 IN 2018
2019
DONATION
FORM
MAKE
YOUR
MARK
MATHEMATICS
IN 2018
YES, I WANT
TO
BE A PART
MATHEMATICS!
YES,
I WANT
TO
BE OF
A ON
PART
OF MATHEMATICS!
ABOUT YOU
YOU
ABOUT
YOU
ABOUT
TITLE
TITLE
TITLE
ABOUT YOU
DR. £ MR.
£ £
PROFESSOR
PROFESSOR £ DR. £
£ PROFESSOR
£ DR.
ABOUT YOU
£ DR.
FIRST NAME
FIRST
TITLE NAME
£ PROFESSOR
FIRST
NAME
MAILING
ADDRESS
£ MRS.
£ MR. MS.
£ £ MRS.
£ MR. £ MRS.
£ MR.
LAST NAME
OTHER
______________
£ MS.
OTHER
£ MRS.
______________
£ MS.
OTHER ______________
LAST
NAME OTHER ______________
£ MS.
LAST NAME
MAILING
ADDRESS
FIRST
NAME
LAST NAME COUNTRY
PROVINCE/STATE
POSTAL/ZIP
TITLE
£
PROFESSOR
£ DR.
£ MR. CODE £ MRS.
£ MS.
OTHER ______________
MAILING
ADDRESS
PROVINCE/STATE
POSTAL/ZIP CODE
COUNTRY
PHONE
EMAIL
MAILING
ADDRESS
FIRST
NAME
LAST
NAME
PROVINCE/STATE
CODE ABOUT UPCOMING EVENTS AND ANNOUNCEMENTS
COUNTRY
£ I WOULD LIKE TO BE ADDED TO THE FIELDS INSTITUTE MAILING EMAIL
LIST POSTAL/ZIP
TO RECEIVE INFORMATION
PHONE
PROVINCE/STATE
POSTAL/ZIP CODE
COUNTRY
MAILING
ADDRESS
ACKNOWLEDGEMENT
PHONE
EMAIL LIST TO RECEIVE INFORMATION ABOUT UPCOMING EVENTS AND ANNOUNCEMENTS
£
I WOULD LIKE TO BE OPTIONS
ADDED TO THE FIELDS INSTITUTE MAILING
PHONE
EMAIL
PROVINCE/STATE
POSTAL/ZIP CODE
COUNTRY
£ I PREFER TO MAKE THIS DONATION ANONYMOUSLY
£ £
I WOULD
TO BE
BE ADDED
ADDED
TO THE
THE
FIELDS
INSTITUTE
EMAIL
LIST
RECEIVE
INFORMATION
ABOUT
UPCOMING
AND ANNOUNCEMENTS
I WOULD LIKE
LIKE TO
TO
FIELDS
INSTITUTE
MAILING
LIST
TO TO
RECEIVE
INFORMATION
ABOUT
UPCOMING
EVENTS EVENTS
AND ANNOUNCEMENTS
ACKNOWLEDGEMENT
OPTIONS
2018 DONATION FORM
YES,
I WANT
TO BE A PART OF MATHEMATICS!
ACKNOWLEDGEMENT
OPTIONS
£ I WOULD LIKE TO DEDICATE MY DONATION IN RECOGNITION OF A MILESTONE, TO CELEBRATE A HOLIDAY, OR IN HONOR OF SOMEONE SPECIAL. PLEASE
PHONE
EMAIL
PROVIDE DETAILS BELOW:
£ I PREFER TO MAKE THIS OPTIONS
DONATION ANONYMOUSLY
ACKNOWLEDGEMENT
£ I WOULD LIKE TO BE ADDED TO THE FIELDS INSTITUTE MAILING LIST TO RECEIVE INFORMATION ABOUT UPCOMING EVENTS AND ANNOUNCEMENTS
£ I PREFER TO MAKE THIS DONATION ANONYMOUSLY
£ I I PREFER
WOULD TO
LIKE
TO DEDICATE
MY DONATION
IN RECOGNITION OF A MILESTONE, TO CELEBRATE A HOLIDAY, OR IN HONOR OF SOMEONE SPECIAL. PLEASE
£
MAKE
THIS DONATION
ANONYMOUSLY
PROVIDE DETAILS BELOW:
ACKNOWLEDGEMENT
OPTIONS
£ I WOULD LIKE TO DEDICATE MY DONATION TO RECOGNIZE A MILESTONE, CELEBRATE A HOLIDAY, OR IN MEMORY OF SOMEONE SPECIAL. PLEASE
£ I WOULD LIKE TO DEDICATE MY DONATION IN RECOGNITION OF A MILESTONE, TO CELEBRATE A HOLIDAY, OR IN HONOR OF SOMEONE SPECIAL. PLEASE
WRITE THE DETAILS BELOW:
DONATION
ABOUT YOU DETAILS
£ I PREFER
MAKE THIS
DONATION ANONYMOUSLY
PROVIDE TO
DETAILS
BELOW:
I WOULD LIKE TO GIVE:
£ $2,000
£ $1,000
£ $500
£ $200
£ $100
OTHER _________
£ I WOULD LIKE TO DEDICATE MY DONATION IN RECOGNITION OF A MILESTONE, TO CELEBRATE A HOLIDAY, OR IN HONOR OF SOMEONE SPECIAL. PLEASE
PROVIDE DETAILS BELOW:
DONATION £ DR.
DETAILS £ MR.
FIRST
NAME DONATION
£ CHEQUE*
£ DETAILS
MONEY
ORDER*
£ VISA
DONATION
DETAILS
I WOULD LIKE TO GIVE:
£ $2,000
£ $1,000
£ $500
TITLE
£ PROFESSOR
PAYMENT METHODS
* PLEASE MAKE PAYABLE TO “THE FIELDS INSTITUTE”
£ $2,000
£ $1,000
DONATION
DETAILS
MAILING ADDRESS
I WOULD LIKE TO GIVE:
PAYMENT
METHODS
CARDHOLDER
NAME
(AS IT APPEARS £
ON $2,000
THE CARD)
I WOULD
LIKE
TO GIVE:
PROVINCE/STATE
£ $500
EMAIL
EXPIRY DATE
* PLEASE MAKE PAYABLE TO “THE FIELDS INSTITUTE”
£ MS.
LAST NAME
£ MASTERCARD
OTHER ______________
£
AMEX
£ $200 £ $100 OTHER _________
£ $200 £ $100 OTHER _________
£ $1,000
£ $500
POSTAL/ZIP CODE
MASTER
CARD / VISA / AMERICAN EXPRESS
ONE)
& NUMBER
£
CHEQUE*
£ (CIRCLE
MONEY
ORDER*
I PAYMENT
WOULD
LIKE
TO GIVE:
£ $2,000
£
$1,000
£ $500
METHODS
PHONE
PAYMENT METHODS
£ MRS.
£ $200
VISA
£ £ $200
£ $100
OTHER _________
COUNTRY
£ MASTERCARD
OTHER _________
£ $100
£
AMEX
CCV OR CVC NUMBER
CHEQUE*
£ MONEY ORDER*
£ VISA
£ MASTERCARD
£ AMEX
• £ £
ONLINE:
FIELDS.UTORONTO.CA/ABOUT/FUNDRAISING
SIGNATURE
DATE LIST TO RECEIVE INFORMATION ABOUT UPCOMING EVENTS AND ANNOUNCEMENTS
I WOULD LIKE
TO BE ADDED TO THE FIELDS INSTITUTE EMAIL
PAYMENT
METHODS
PLEASE MAKE PAYABLE TO
“THE FIELDS
INSTITUTE”
• * CHEQUE/MONEY
ORDER:
PAYABLE
TO “THE FIELDS INSTITUTE”
NAME (AS OPTIONS
IT APPEARS
ON THE CARD)
ACKNOWLEDGEMENT
£ CARDHOLDER
CHEQUE*
£ VISA
OPTIONS
FOR SUPPORT (SELECT
ONE) £ MONEY ORDER*
• CREDIT CARD (COMPLETE DETAILS BELOW)
£
TO
MAKE
THIS
DONATION
ANONYMOUSLY
£ I PREFER
THE MAKE
INSTITUTE’S
NEEDS
£ MATHEMATICS
AND EDUCATION
MASTER
CARD
/ GREATEST
VISA
/ (AS
AMERICAN
EXPRESS
(CIRCLE
NUMBER
* CARDHOLDER
PLEASE
PAYABLE
TO “THE
FIELDS
INSTITUTE”
NAME
IT APPEARS
ON THE
CARD) ONE) & OUTREACH
£ MASTERCARD
£
AMEX
£ FIELDS MEDAL SYMPOSIUM
£ RECOGNIZE
SCIENTIFIC PROGRAMMING
AND EVENTS
£
I VISA
WOULD
LIKE / TO
DEDICATE
MY
TO
MILESTONE,
CELEBRATE
A HOLIDAY, OR IN MEMORY OF SOMEONE SPECIAL. PLEASE
DATE
CCV OR
CVC NUMBER
£ EXPIRY
£ DONATION
MASTERCARD
£ AMEX
MASTER
CARD
VISA
/ AMERICAN
EXPRESS (CIRCLE
ONE) & A NUMBER
WRITE THE DETAILS
BELOW:
CARDHOLDER
NAME (AS
IT APPEARS ON THE CARD)
SIGNATURE
DATE
CARDHOLDER’S
NAME (AS IT APPEARS ON THE CARD)
EXPIRY DATE
CCV OR CVC NUMBER
MASTER CARD / VISA / AMERICAN EXPRESS (CIRCLE ONE) & NUMBER
SIGNATURE
DATE
CREDIT
CARD NUMBER
OPTIONS
FOR SUPPORT (SELECT ONE)
EXPIRY
DATE
CCV OR CVC NUMBER
THANK YOU FOR SUPPORTING THE FIELDS INSTITUTE
EXPIRY
£ THE DATE
INSTITUTE’S GREATEST NEEDS
DONATION DETAILS
CCV OR CVC NUMBER
£ MATHEMATICS
OUTREACH AND EDUCATION
SIGNATURE
DATE
TAX-DEDUCTIBLE
RECEIPTS
WILL BE ISSUED TO ALL CANADIAN RESIDENTS. PLEASE
ALLOW FOR A THREE WEEK TURNAROUND TIME.
OPTIONS FOR SUPPORT
(SELECT
ONE)
SIGNATURE THE FIELDS INSTITUTE HAS A STRICT PRIVACY POLICY. ALL DONOR INFORMATION IS CONFIDENTIAL AND DATE
WILL NOT BE DISTRIBUTED TO EXTERNAL ORGANIZATIONS
£ FIELDS MEDAL SYMPOSIUM
NON-ANONYMOUS DONOURS WILL BE ACKNOWLEDGED BY NAME IN THE INSTITUTE’S NEWSLETTER AND ANNUAL REPORT.
£ THE INSTITUTE’S GREATEST NEEDS
SCIENTIFIC PROGRAMMING
AND EDUCATION
EVENTS
£ MATHEMATICS
OUTREACH AND
OPTIONS FOR SUPPORT (SELECT ONE) THE FIELDS INSTITUTE FOR RESEARCH IN MATHEMATICAL SCIENCES
£ FIELDS MEDAL SYMPOSIUM
222
ST. | TORONTO
| ONTARIO
CANADA
M5T PROGRAMMING
3J1 | WWW.FIELDS.UTORONTO.CA
I SUPPORT
WOULD LIKE
TO GIVE:
£ COLLEGE
$2,000
£ $1,000
£ | $500
£ $200
£ | SCIENTIFIC
AND EVENTS £ $100
OPTIONS
(SELECT
ONE)
£ THE INSTITUTE’S
GREATEST
NEEDS
£ MATHEMATICS OUTREACH AND EDUCATION OTHER _________
£ FIELDS MEDAL SYMPOSIUM £ SCIENTIFIC PROGRAMMING
PAYMENT METHODS
£ UNDERGRADUATE SUMMER RESEARCH PROGRAM
£ FIELDS MEDAL SYMPOSIUM
THANK YOU FOR SUPPORTING THE FIELDS INSTITUTE
• CHEQUE/MONEY
PAYABLE
TO “THE SUPPORTING
FIELDS INSTITUTE”
THANK ORDER:
YOU
FOR
THE FIELDS INSTITUTE
• CREDIT CARD (COMPLETE DETAILS BELOW)
THANK
SUPPORTING THE
THE FIELDS
FIELDS INSTITUTE
INSTITUTE
THANK YOU
YOU FOR SUPPORTING
£ SCIENTIFIC PROGRAMMING AND EVENTS
PUBLIC LECTURES
£ GRADUATE STUDENTS AND POST DOCS
• £ ONLINE:
FIELDS.UTORONTO.CA/ABOUT/FUNDRAISING
£ 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
IS CONFIDENTIAL
AND WILL
BE DISTRIBUTED
TO EXTERNAL
TAX-DEDUCTIBLE
RECEIPTS
WILL
BE ISSUED
TO ALL INFORMATION
CANADIAN RESIDENTS.
PLEASE ALLOW
FOR NOT
A THREE
WEEK TURNAROUND
TIME. ORGANIZATIONS
NON-ANONYMOUS DONOURS WILL BE ACKNOWLEDGED BY NAME IN THE INSTITUTE’S NEWSLETTER AND ANNUAL REPORT.
£ MASTERCARD
£ FOR
AMEX
THE FIELDS INSTITUTE
RESEARCH IN MATHEMATICAL SCIENCES
THE FIELDS INSTITUTE HAS A STRICT PRIVACY POLICY. ALL DONOR INFORMATION IS CONFIDENTIAL AND WILL NOT BE DISTRIBUTED TO EXTERNAL ORGANIZATIONS
222 COLLEGE ST. | TORONTO | ONTARIO | CANADA | M5T 3J1 | WWW.FIELDS.UTORONTO.CA
TAX-DEDUCTIBLE RECEIPTS WILL BE ISSUED TO ALL CANADIAN RESIDENTS. PLEASE ALLOW FOR A THREE WEEK TURNAROUND TIME.
TAX-DEDUCTIBLE RECEIPTS WILL BE ISSUED TO ALL CANADIAN RESIDENTS. PLEASE ALLOW FOR A THREE WEEK TURNAROUND TIME.
CARDHOLDER’S NAME (AS
IT APPEARS DONOURS
ON THE
CARD)
NON-ANONYMOUS
WILL
BE ACKNOWLEDGED
BY NAME IN
INSTITUTE’S NEWSLETTER
THE
FIELDS
INSTITUTE FOR RESEARCH
IN THE
MATHEMATICAL
SCIENCES AND ANNUAL REPORT.
NON-ANONYMOUS DONOURS
WILL
BE
ACKNOWLEDGED
BY
NAME
IN 3J1
THE
INSTITUTE’S
NEWSLETTER/ANNUAL REPORT
222
COLLEGE
ST. | ALL
TORONTO
ONTARIO | CANADA
| M5T
|
WWW.FIELDS.UTORONTO.CA
THE FIELDS INSTITUTE HAS A STRICT
PRIVACY
POLICY.
DONOR | INFORMATION
IS CONFIDENTIAL
AND
WILL NOT BE DISTRIBUTED TO EXTERNAL ORGANIZATIONS
£ VISA
THE
FIELDS
INSTITUTE
HAS A STRICT PRIVACY POLICY: ALL DONOR INFORMATION IS CONFIDENTIAL AND WILL NOT BE SHARED WITH OTHER ORGANIZATIONS.
CREDIT
CARD
NUMBER
EXPIRY DATE
THE FIELDS INSTITUTE FOR RESEARCH IN MATHEMATICAL SCIENCES
222 COLLEGE
ST. | TORONTO
| ONTARIO
| CANADA | IN
M5T
3J1 | WWW.FIELDS.UTORONTO.CA
THE FIELDS
INSTITUTE
FOR RESEARCH
MATHEMATICAL
SCIENCES
CCV OR CVC NUMBER
222 COLLEGE STREET, 2ND FLOOR| TORONTO | ONTARIO | CANADA | M5T 3J1 | WWW.FIELDS.UTORONTO.CA