SHS SCHOLARSHIP FUND DONATION FORM
Name:_____________________________________________________________________________
Member Number:____________________________________________________________________
As evidence of my desire to provide a legacy of support for IIE’s Society for Health Systems (SHS), I
wish to make a gift by:

Check for $___________ enclosed.
Please make checks payable to “IIE”. Memo: “SHS Scholarship”

Credit Card for $___________
Credit Card Number_________________________________ Expiration__________________

This donation qualifies for matching funds through an employer.
Employer name: _____________________________
I designate this gift to be used for the SHS Scholarship Fund.
Thank you for your tax-deductible donation.
Your receipt for tax purposes will be send as soon as we receive your gift.
In recognition of your donation, we would like to acknowledge you by publicizing your name on our
donor list and including you in any future recognition activities.

Yes, you may publicize my name on the donor list, which serves as a motivation for others to
consider planned gifts in support of SHS.

I prefer my intentions to remain anonymous.
Donor Signature________________________________________________Date___________________
Address______________________________________________________________________________
Phone number (hm)________________________________(cell)________________________________
E-mail address________________________________________________________________________
Please mail to IIE, 3577 Parkway Lane, Suite 200, Norcross, GA 30092.
If making a payment by credit card, you may also fax this form to 770-441-3295.