DUBIN BREAST CENTER ANNUAL BENEFIT GALA

DUBIN BREAST CENTER ANNUAL BENEFIT GALA MONDAY, DECEMBER 11, 2017 HONORING KARA DIOGUARDI • BROOKE MORROW PHYSICIAN HONOREE STEVEN J. BURAKOFF, MD ZIEGFELD BALLROOM, NEW YORK CITY PLEASE ADD MY NAME AS A CO-CHAIR AND RESERVE THE FOLLOWING: O ONE PLACE TABLE(S) AT $100,000 (10 tickets) Priority seating, special recognition during the evening, listing in the printed program, and listing on Dubin Breast Center Annual and Permanent Donor Walls. O ONE MISSION TABLE(S) AT $50,000 (10 tickets) Premium seating, special recognition during the evening, listing in the printed program, and listing on Dubin Breast Center Annual Donor Wall. O ONE TEAM TABLE(S) AT $25,000 (10 tidcets) Prime seating, listing in the printed program, and listing on Dubin Breast Center Annual Donor Wall. PLEASE ADD MY NAME TO THE BENEFIT COMMITTEE AND RESERVE THE FOLLOWING: O ONE PURPOSE TABLE(S) AT $15,000 (10 fickets) (limited availability) Listing in the printed program and listing on Dubin Breast Center Annual Donor Wall. PLEASE RESERVE THE FOLLOWING: O ONE ROOF SINGLE TICKET(S) AT $2,500 EACH Seating for dinner and listing in the printed program. O ONE INDIVIDUAL SINGLE TICKET(S) AT $1,500 EACH Seating for dinner and listing in the printed program. O I am unable to attend but wish to make a contribution of $ (Please list name and/or company above as you wish it to appear in print) NAME COMPANY ADDRESS CITY STATE ZIP E-MAIL PHONE FAX I WISH TO CHARGE THIS GIFT TO: [ ] AMEX [ ] MASTERCARD [ ] VISA [ ] PERSONAL CREDIT CARD [ ] CORPORATE CREDIT CARD NAME ON ACCOUNT CREDIT CARD NUMBER EXP DATE SIGNATURE Please make checks payable to the Icahn School of Medicine at Mount Sinai (Tax IDA 13-6171197) and return to Event Associates, Inc., 162 West 56th Street, Suite 405, New York, NY 10019. Contributions are tax-deductible to the extent provided by law. Each table is tax-deductible less $2,750 and each ticket is tax-deductible less $275. Gifts from donor advised funds, foundations, and charitable trusts may not be used for purchases that provide tangible benefits to any individual. Tax receipts will be mailed after the conclusion of the event. For further information, lease contact Debbie Fife or Emil Kline: Mora xt. 20 or ext. 23, Fax: , E-mail: To leam more about the Dubin Breast Center please visit our website at www.dubinbreastcenter.org or call 212-659-8500. If you wish to have our name removed from our distribution list of fundraising materials, please contact us by telephone or email your name and address to PhilanthropyOptOutamountsinai.org. A Mount Dubin Breast Center Sinai Th. rathcmya rases EFTA00800309