Package Name Amount Quantity Subtotal

Distinguished Philanthropist (12 included) $0.00

Major Benefactor (10 included) $0.00

Steward of Honor (4 included) $0.00

Distinguished Ambassador (2 included) $0.00

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I authorize Mercy Health Foundation - Clark & Champaign Counties to use the credit card entered on the submission page at event Mercy Health Foundation Clark and Champaign Counties Gala 2023. Once the transaction has completed successfully, a confirmation receipt will be sent to the email address entered.