Name/Corporate Name*
Corporate Contact
ID Number
Street*
City*
State*	Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code*
Telephone*
Email
Name(s) for Football Game Program

	New Member
	Renewal Member
	This pledge is an increase over last year's pledge
	This pledge will be matched by: (name of company or organization) More information
	I am/My spouse is eligible for the Under 30 discount. Birth date:
	I am/My spouse is a UNI employee, therefore I am eligible for a match. More information

$ My annual contribution amount

Platinum Panther ($12,000+) Diamond Panther ($7,000+) Scholarship ($3,500+) UNI Pride ($2,500+) VIP ($1,700+) Directors ($1,250+) Gold ($850+) Purple ($450+) Coaches ($250+) Loyalty ($150+)

Your eligibility for a level depends on your annual contribution amount and additional discounts based on your your membership information

Credit Card:

Amount
Credit Card	VISA MasterCard Discover American Express
Number
Expiration Date
Name on Credit Card

	Direct Payment from my checking or savings account (You must complete an Authorization for Direct Payment form. Please mail form to address at the bottom of the form.)
	Recieve a monthly reminder for the full amount pledged unless other arrangements are made with the Panther Scholarship Club.
	I would like to pledge to be payroll deducted from my UNI paycheck. (You must complete and sign a Payroll Deduction Form. Please mail form to address at the bottom of the form.)
	Gift-In-Kind/Trade Gift. Please provide a description of gift or services:
	All gifts-in-kinds/trade gifts must be pre-approved by the Panther Scholarship Club.

	Check here if you would like to recieve our weekly email updates
	Check here if you are interested in season tickets for any of our sports

Please list their name and contact information, if known:

friend/family funddrive volunteer website UNI athletic event other

Signature

By placing an 'X' in the Signature field, you are agreeing to the above statements.

*Required fields