 |
|
| Name: |
_________________________________________ |
| Address: |
_________________________________________ |
| City: |
___________________ |
State: |
_____________ |
| Zip: |
___________________ |
|
|
| Phone: |
(___)_______________ |
Fax: |
(___)_________ |
| Email: |
__________________________________________ |
| Check the Program or Programs that you would like to contribute to: |
| ___ |
MentorCares Program |
| ___ |
LiteracyCares Program |
| ___ |
Annual Thanksgiving Basket Program |
| Check___ MasterCard____ Visa___ American Express ___ |
| Credit Card #: |
________________________________________ |
| Exp. Date: |
________________________________________ |
| Donation Amt: |
________________________________________ |
| Signature: |
________________________________________ |
Please fax this completed form to:
Leadership Cares
301-253-4233
or mail it to:
Leadership Cares Foundation
10181 Nightingale Street
Gaithersburg MD 20882 |
| |
|
