TSO Network Update - September 2017

September 2017 l 13 Thank you. You can also mail, fax or email this form to: Optometry Giving Sight, 1019 8th Street, Suite 304, Golden CO 80401 T: 888 OGS GIVE F: 303 279 8042 E: usa@givingsight.org Donations can also be made online at: www.givingsight.org All donations are tax deductible. General Details: Title: First name: Last name: Company / Practice: _____________________________________ Telephone: Address: _______________________________________________ City/State/Zip: ___________________________________ Fax: Email: Practice Manager / Contact name: Email: Payment options I will make my donation now! Check enclosed Credit card information below Donation amount $ Card number Expiration date Signature I prefer to be invoiced after the Challenge, at the level checked above. I would like my gift to be used for: Child eye health Training more optometrists I will let Optometry Giving Sight allocate my gift to wherever the need is greatest Suggestions for practice fundraising: • Donating $2 (or other amount) for every pair of glasses sold during October • Donation based on the number of exams given during October • Patient fundraising (“sell” wristbands and keychains, etc.) • Matching patient donations • Fundraising event (i.e., trunk show or raffle) My level of commitment Platinum Supporter $1,500+ Gold Supporter $1,000 - $1,499 Silver Supporter $500 - $999 Bronze Supporter $250 - $499 Other donation amount Please send me a free WSDC Practice Kit for my donation of $250 or more, which includes wristbands, keychains, donor cards, balloons, stickers, a counter card, and more to celebrate World Sight Day with my patients! YES, I would like to take the 2017 World Sight Day Challenge!