Physician Sponsor Form

We appreciate your generous support of ASIPP!

This contribution will assist in the educational and operational costs, which we believe, are necessary for the advancement of interventional pain management and the preservation of patient access to this vital, life-enhancing care. It is through the support of ASIPP that we are able to do the mission of ASIPP in preserving and developing interventional pain management through education, research and much more.

First Name:*

Last Name:*

Organization:

Address:*

City:*

State:*

Zip:*

Phone:*

Fax:

E-mail:*

Contributions to section 501(c)(6) organizations are tax deductible on the donor’s federal income tax return as trade or business expenses if ordinary and necessary in the conduct of the taxpayer’s business. Contributions are not deductible as charitable contributions.

Contribution Giving Levels

Individuals:

Supporter $500

Advocate $1,000

Promoter $1,500

Champion $2,500

Physician Corporation:

Supporter - $5,000

Advocate - $10,000

Promoter - $15,000

Champion - $25,000

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Contribution Amount*

USDDonation

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