Personal Information

First Name:*
Middle Name:
Last Name:*
Relation:	Alumni Parent Friend Student Faculty Staff Other
Class:

Parent Of

First Name:
Middle Name:
Last Name:
Class:

Contact Information

Home Address Business Address
Street Address: *	City: *
State / Province: *	Country:*
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories and Nunavut Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories Other / None	Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Congo, The Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic Republic of (North) Korea, Republic of (South) Kuwait Kyrgyz Republic Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Re'union Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe
Zip Code: *
Email Address: *
Email type *	Home Account Business Account
Home Phone Number:
Business Phone Number:

Gift Details

My Gift Amount: *	$10,000 $5,000 $2,500 $1,000 $750 $500 $250 $150 $100 $75 $50 $35 Other
If "Other", enter amount: ($10 minimum)
Gift Designation:	Choral Music Program Pledge Payment Current Unrestricted - Alumni Fund Current Unrestricted - Parents Fund Current Unrestricted - Friends of Oxy Current Year Scholarship ($10,000) Undergraduate Summer Research Scholarship Academic Quad Benches ($5,000 or $7,500) Tiger Club Latino Endowed Scholarship Cleveland Gillis Memorial Endowed Scholarship Fifty Year Club Annual Scholarship Alpha Sorority Scholarship Delta Sorority Scholarship Voluntary Magazine Subscription Other

Click here for more information about Current Year Scholarship.

Click here for more information about Academic Quad Benches.

	Please send me the DTC Wire Transfer instructions to provide my stock broker.
	Please contact me about how I might join the Ben Culley Society by making a planned gift such as a bequest, trust, or gift annuity.
	Please send me payroll deduction authorization forms. (for Occidental College Employees only)

Would you like to make a...

One Time Donation
Payment will be processed only once.
Recurring Donation
Payment will be automatically deducted from your credit or checking account for a specified time period.
Repeat this donation:
Quarterly for 1 year Once per month for 2 months Once per month for 3 months Once per month for 4 months Once per month for 5 months Once per month for 6 months Once per month for 7 months Once per month for 8 months Once per month for 9 months Once per month for 10 months Once per month for 11 months Once per month for 12 months

Comments

If your employer will match your gift, please also include employer's name and contact info here:

If your employer will match your gift, please send a completed matching gift form to:

1600 Campus Road
Los Angeles, CA
90041-3314