Pledge Form

Jake With Open Scissors by Wichita artist Patrick Duegaw.

*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Phone:	Example: xxx-xxx-xxxx
Email:

*Required Field
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I am:
a New Member a Renewing Member Making An Additional Pledge

Pledge Levels

$1200 Tesla Society: 3 Day Sponsorships + Signed Artist Print + Tote89 + Mug + Shirt + Card89

$900 Producer's Circle: 2 Day Sponsorships + Signed Artist Print + Tote89 + Mug + Shirt + Card89

$600 Broadcaster's Circle: Day Sponsorship + Signed Artist Print + Tote89 + Mug + Shirt + Card89

$300 Announcer's Circle: Day Sponsorship + Tote89 + Mug + Shirt + Card89

$225 Day Sponsorship or Card89 + Tote89 + Mug + Shirt

$189 Mug + Shirt

$175 Mug + Tote89

$135 Shirt

$100 Mug

$89 Card89

$60 Tote89

I would like to pledge:

$1200 $900 $600 $300 $225 Premium Level $225 Day Sponsorship $189 $175 $135 $100 $89 $60 Other

$Dollars only / no commas

_________________________________________________

May we thank you on-air?
Yes No

Are you interested in premiums?
Yes No

Will you pick up your premiums?
Yes No, please mail.

Do you want the Card89?
Yes No

What size T-shirt would you like?
No Shirt Small Medium Large XL 2X

Will your employer match your pledge?
No Yes

What is your employer's name?

Do you have any comments?
Please submit your Day Sponsorship information here, or call Pat Hayes at 978-7171 to schedule a Day Sponsorship.

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How would you like to pay?
Pay Now with E-Check or Credit Card (recurring payments available) Please send me a bill. I will stop by the station and pay. I would like to setup a WSU Payroll Deduction plan.

For the WSU Payroll Deduction plan you may download the necessary form here, or:
I will stop by the station and fill out my form. I will print off and mail my form. Please mail me a form.