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Order Request Form
For best experience, utilize this form on a desktop computer.
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1
Contact Information
Donor Name
Empl ID
Clinical Department
Development Officer
Email (You will receive a copy of this submission)
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2
Additional Email Recipients
The following email accounts will receive a copy of this submission.
Additional Email Recipients
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3
Plaque Size
Select the size of plaque that you would like to order.
20" x 14" ($1 Million+)
18" x 12" ($500,000)
12" x 12" ($250,000)
9" x 9" ($100,000)
6" x 6" ($50,000)
2.5" x 8.5" ($25,000)
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4
Plaque Criteria
Recognition Statement (i.e. - In Appreciation of, We are grateful to, In honor of etc.)
Donor Name
Support Statement (Italicized Text)
Honoree Statement at bottom [if applicable] (i.e. - In Honor of)
Honoree Name [if applicable]
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5
Installation Information
Complete to the best of your ability. You may leave some fields incomplete.
Event Date or Deadline
Building Name
Floor #
Room #
Wing
Type of Room (i.e. - Exam Room, Consultation, etc.)
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6
(Optional) Location Photo Uploader
Upload a photograph of the install location if you are requesting a mock-up proof of the plaque in its desired destination. There is a $30 production art charge for this special request.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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