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UCLA Ophthalmology Alumni Association Membership Contribution 2023-2024

Required fields are indicated with an asterisk (*).

RSVP Information

Membership Contribution
Select	Description	Amount

2023-24 Membership Contribution - $100 (tax-deductible)

Sub-Total:
Tax-Deductible:

I would like to make a fully tax-deductible gift of * Other $ *

Grand Total:

Tax-Deductible:

Contact Information

Personal

Title:

*

First name:

*

Middle name:

*

Last name:

*

Suffix:

I am making this gift as a proxy for my organization/company, which should be recognized as the legal donor

Contact Information

*

Street:

*

U.S. Addresses

*

City, State, Zip:

*

Non-U.S. Addresses

Non-U.S. City/County
or Province/Postal Code:

*

Country:

*

This address is my:

Home

Business

*

Home telephone:

Invalid phone number *

Business telephone:

Invalid phone number

*

E-mail address:

*

This e-mail is my:

Home

Business

*

Payment

Payment method:

Credit Card PayPal

Additional Information

Comments:

If you have any questions about this donation, please contact:

Teresa Closson
Stein Eye Institute Development Office
310-825-4148
alumni@jsei.ucla.edu

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