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Fill out this following form and submit it to intlalumni@uwlax.edu                                    Click here to Download document

 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__

OFFICE USE ONLY

UW-L FOUNDATION, INC.                                                                             

 

Estimated cost for

information $_________

By______________________________________________