Contribution Form

201 Membership Form
Yes! I want to support the Baylor College of Dentistry Alumni Association
with a gift to the Membership Fund.
$150 Century Club
$500 Scholars Club
$250 McCarthy Associates
$1,000 Dean’s Club
Dentist
Dental Hygienist
Name
Faculty
$
Student/Resident
Class
Or charge $
State
Email
oFFICe
Address
Office
Pledge - I want to join with a pledge
City
State
TOTAl pledged $
To be paid:
Monthly
Quarterly
Semi-annually
Zip
Phone
Email
Your Specialty
Spouse
STATUS:
to my Visa© / MC©
Card No.
Exp.
Security code
Cardholder’s name
Signature
Credit card billing address:
Home
Zip
Phone
Friend of the Association
Enclosed is my check for $
payable to BoHF/BCD Alumni Association Fund
Home
Address
City
(Other Amount)
Active
Retired
Student
Spouse
SeND Mail to:
Home
Office
Pay each installment:
By check (bill me)
Automatically by credit card
(please complete credit card info above)
Thank You!
Your membership fees are deposited into the Alumni Association account managed by the Baylor Oral Health Foundation,
a tax exempt (501(c)3) charitable organization. Because your fees are tax deductible, you will receive a letter from
the BOHF for tax purposes.
Go to
bcd.tamhsc.edu/alumni
and sign up
to receive campus
and alumni updates!
Mail to:
BCD Alumni Association
3302 Gaston Avenue, Suite 522, Dallas, TX 75246 • 214.828.8202 • Fax 214.874.4529