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*First Name:
*Last Name:
E-mail:
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Fax:
*Address Line 1:
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*City:
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Pledge Amount: (in US dollars):

Bench Club Benefits
If you choose to receive benefits, you cannot claim the above amount pledged on your personal/business income tax return as a tax deduction. Find out more about the Bench Club benefits and deductions. If you do not plan on claiming the tax deduction, check the "Yes" box below.

*Would you like to receive benefits? Yes No

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