Make an

impression
that lasts...
kimberly m
wagner

BA 01
MPA 05

Name ____________________________________________________________________________________
Address __________________________________________________________________________________
City/State/Zip ______________________________________________________________________________
Current Phone _____________________________________________________________________________
E-mail ___________________________________________________________________________________
PAYMENT OPTIONS
One Triangle ($50.00)

Please print information as it should read on the triangle:

Name
Line one

Line two

IPFW Degree (BA) and graduation year (89)

Line three

Line four

1. Check: Enclosed for $ _________________________________. Make check payable to: IPFW Foundation
Mail to IPFW Alumni Relations, 2101 E. Coliseulm Blvd, Fort Wayne, IN 46805
2. Credit Card: Charge $ ________________ to my credit card.
actual size

Visa

MasterCard

Discover

Account Number ___________________________________________________________________________

... and be a part of the

IPFW Alumni Center forever.

Expiration Date ________________________________________________ CSC _______________________

Card Holders Name ________________________________________________________________________
Card Holders Address ______________________________________________________________________
Signature _____________________________________________________Date _______________________