ASRM Bequest Disclosure and Legacy Society Enrollment Form

Thank you for selecting ASRM for your legacy!

Thank you for including reproductive medicine in your estate plans through your bequest to ASRM. We are grateful for your thoughtfulness and generosity, which will advance the field of reproductive medicine.

Please use this form to share details about your future gift. We understand that your gift is revocable and that you may change your plans at any time.

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* 1. I have included ASRM, ASRM Research Institute, or an ASRM affiliate society in my:

Will

Trust

Life Insurance

Beneficiary designation

Other (please specify)

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* 2. My bequest is worth approximately $____________________. (Please provide a good faith estimate based on the approximate current value,)

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* 3. I would like to be recognized as _______________________________________________. (Most listings are first, middle, last name, and credentials, such as MD. Many choose to be listed with their spouse such as Drs. Mary and Jon Jones.)

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* 4. Do you want your bequest to be anonymous?

Yes

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* 5. Please provide your mailing address.

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number