Benefit Committee Registration Form

16th Annual New York Benefit Dinner October 26, 2009 Pier Sixty at Chelsea Piers Advance Table Reservation Form _____

I would be delighted to join the New York 2009 Benefit Committee

_____

I will be unable to serve this year

I will support Facing History and Ourselves’ New York program at the following level: _____ Premier Benefactor $100,000 _____ Platinum Benefactor $75,000 _____

Golden Benefactor $50,000

_____ Silver Benefactor $25,000 _____ Bronze Benefactor $15,000 _____ Benefactor $10,000 _____ Patron $7,500 Tables seat 10.

I will be filling ____ table(s).

_____ I am enclosing $__________________. _____ Consider this a pledge for $__________________. ____________.

Please expect payment by

_____ I cannot attend but am enclosing a contribution of $ __________________.

Gifts and Pledges of $7,500 and above will be listed in the Dinner invitation and in the Dinner program. Deadline for listing in the invitation is July 10th. Deadline for listing in the Dinner program is September 14th. Name(s) (As you wish it to appear): Title if applicable: Company/Institution if corporate sponsorship: Address: City: State: Zip: Phone (H): (W): Fax: E-Mail address: __________________________________________________________________________________ __

For additional information please contact Emily Barrett at (212) 992-7390 You may fax this form to Emily Barrett at (212) 995-4430 or mail it to: Emily Barrett Facing History and Ourselves 14 East 4th Street, Suite 3003 New York, NY 10012