Name:
E-mail address (if you have one):
Fax (if you have one):
Phone (otherwise):
Value of Donation:
Currency of Donation:
Donation enclosed:
-- or --
Please charge:
Visa [ ] MasterCard [ ] American Express [ ]
Credit card number:
Expiration date:_____
Name as it appears on card:
Do you wish your donation to be kept
anonymous? No [ ] Yes [ ]
