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Donation Form 1

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Donation Form 1
Donation Form 1
Donor information
First Name ____________________________ Last Name ____________________________
Address
_____________________________________________________________________
City
_________________________________
State
_________________________________
Zip Code
_____________________________
Country
_______________________________
Phone
_______________________________
E-Mail
_________________________________
Donation form
Whether you are a long time March of Dimes supporter or are giving for the rst time,
thank you for your commitment to helping babies be born healthy. Please use this form
to mail or fax your donation. If you have a special request, please contact us at
[email protected].
Mail or fax your completed form along with your donation to:
March of Dimes
Attention: DRFR
1275 Mamaroneck Avenue
White Plains, New York 10605
Fax: 914-997-4537 (Credit Card only)
code – 3IN
Donation
Donation Amount $
________________
(in US currency)
My check is enclosed
Please charge my credit card Card Type
Card Number ______________________________ Expiration
_________________________
Name of cardfolder _________________________ Signature
_________________________
Billing Address: (if different than above)
Address
_____________________________________________________________________
City
_________________________________
State
_________________________________
Zip Code
_____________________________
Country
_______________________________
(Please print out the form and sign)
Donation Form 1
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