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UNIVERSITY OF WISCONSIN-LA CROSSE FOUNDATION, INC.
REQUEST FOR RELEASE OF INFORMATION
Name of Individual/Organization__________________________________Date _____________
Address_______________________________________________ Telephone______________
Chief Officer of Organization______________________________ Telephone______________
If applicable, Faculty/Staff Advisor_________________________ Telephone______________
Person Responsible for Information__________________________ Telephone______________
Fund Reports: ___ Gifts ___Expenses ___ Activity Summary
Reporting period requested: Beginning date ______ Ending Date______
____ Donors names required
Form of information requested: ____ List ____Labels ____Disk ________________Other
Sort by: _____Alpha _____Zip code _____Grad years __________________________Other
When information is needed___________ When information will be used____________
Type of Information Requested:
Alumni: Names and addresses only ____ yes ____no
Phone numbers ___yes ____no
Grad years _____________________________ zip code/area________________
Majors____________________________________________________________
Other interest or criteria______________________________________________
Donor's identified? ____ yes ____no
Non Alumni: Names and address only ____ yes ____no
Phone numbers ____ yes ____no
Other criteria____________________________ zip code/area_______________
Donor's identified? ____ yes ____no
Intended use of information:_________________If fund raising solicitation:_________________
Who will be solicited?________________________________________________
Purpose of solicitation?_______________________________________________
How will solicitation be conducted?_____________________________________
Where do the proceeds go?____________________________________________
Please attach any literature that will be used for mailings or other distribution.
If other than a unit of the University or University affiliated organization, please attach a copy of determination letter from IRS verifying that the organization is recognized as tax exempt.
The undersigned hereby acknowledges that all of the statements and representations made above are true and accurate to the best of his/her knowledge; that the information requested will be used only in the manner and for the purpose indicated above; that the undersigned understands that he/she is responsible for the control and management of said information such that its confidentiality is protected and preserved; and that the undersigned is responsible for payment before delivery of costs and charges for said information.
University Acct. # to be charged: __________________________________________________
_____________________________________________ _________________
Signature Date
This request approved this ________ day of ___________, 19__
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OFFICE USE ONLY |
UW-L FOUNDATION, INC.
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Estimated cost for information $_________ |
By______________________________________________