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OM - 729 (REV. 11-65)
THE OLIN PLAN
FOR MATCHING GIFTS TO EDUCATIONAL INSTITUTIONS
INSTRUCTIONS: (1) The employee should fill out PART A and
transmit the entire form with his or her contribution to the educa-
tional institution.
(2) Upon receipt of the contribution, the institution should fill
out and execute PART B, and then return this entire form to
Mr. M.A. d'AMELIO at the address shown below.
(3) See reverse side for provisions of plan.
Enclosed is my personal contribution to:
DATE CONTRIBUTION MAILED
(Name & Address of educational institution alumni fund, foundation or association)
February 12, 1971
Vanderbilt University Medical School
CASH
< CHECK
AMOUNT
Nashville, Tennessee_ 37203
$ 50.00
PART
I hereby authorize the institution named above to report this gift to the OLIN MATHIESON CHARITABLE TRUST for the purpose
of qualifying for a contribution from the TRUST in accordance with the provisions of its plan for matching gifts to educational
institutions.
( To be
filled
in
by OLIN
( SIGNATURE)
employee)
PRINT NAME (First, Middle, Last)
PLANT OR OFFICE
Dr. Richard Henderson
New Haven
1-K-5
HOME ADDRESS (Street)
DIVISION Corporate Medical-
Hilltop Road
Environmental Hygiene & Toxicology
CITY & STATE
DATE EMPLOYED
Bethany, Connecticut 06525
March 21, 1955
YOUR RELATIONSHIP TO
EDUCATIONAL INSTITUTION:
ALUMNUS
PARENT
FRIEND
OTHER
I hereby certify that the contribution described above was received by:
(Name and address of educational institution, alumni fund, foundation or association)
PART
To be
filled
In
on
from
by
Name of employee
financial
and that the organization qualifies under the provisions of this plan to receive a grant from the
officer
OLIN MATHIESON CHARITABLE TRUST.
of
(Signature of Financial Officer)
the
NAME AND ADDRESS OF EDUCATIONAL INSTITUTION
PRINT NAME OF FINANCIAL OFFICER
educational
TITLE
institution)
DATE CERTIFICATION IS MAILED
MR. M. A. d'AMELIO
ADDRESS ALL CORRESPONDENCE TO:
OLIN MATHIESON CHARITABLE TRUST
ACOXPARKXAXENNEX
NEWYORKXNXXYORK X082X
(NOTE: SEE REVERSE SIDE FOR PROVISIONS OF PLAN)
120 Long Ridge Road
Stamford, Conn. 06904
s://www.industrydocur
f.edu/docs/atxb0228

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