| First Name | M.I. | Last Name |
| Address |
| City | State | Zip Code |
| Country | Email Address |
| Home Telephone | Work Telephone |
| Comments |
| Total amount of gift to the General International Fund for Excellence |
| Gift made in memory of / in tribute to |
| Notify the following party of this gift (name and address) |
Please make checks payable to the UC Davis Foundation. After completing the form, please print it, and mail it to University of California at Davis, University Outreach and International Programs, Robert A. Kerr, 220 Mrak Hall, One Shields Avenue, Davis, CA 95616.