|
 PAVE
THE WAY
TO A CURE CAMPAIGN
FAX ORDER FORM Please Fax or
Mail This Form with Payment to:
National Osteoporosis Foundation Pave the Way to a Cure Campaign
1232 22nd Street NW, Washington, D.C. 20037-1292
Fax:202-223-2237.
Yes, I want to help Pave the Way to a Cure. I have
indicated at which level I would like to support.
|
__$100.00 |
My name listed on a brick in front of
the NOF headquarters building |
|
__$1,000 |
My name listed on the bronze plaque in
the headquarters lobby. |
|
__$2,500 |
My name listed on the silver plaque in
the headquarters lobby. |
|
__$5,000 |
My name listed on the gold plaque in
the headquarters lobby. |
Name:_________________________________
Street Address:_______________________________
City:_____________________ State:____ Zip:________
Form of Payment (Please Check One):
__Check (made payable to National Osteoporosis
Foundation)
|
__Credit card |
Type: |
__AMEX
|
__MC
|
__VISA
|
Expiration:________
Credit card number:______________________
Signature:______________________________
Name to appear on brick (3 lines of no more than 14
characters each, including spaces)
_________________________________
_________________________________
_________________________________
__I am not interested in "buying a brick,"
but I do want to participate in the Paving the Way to a Cure Campaign.
Please accept my contribution of $
__This brick is a gift
- Please send notification of this gift to:
Name:_________________________________
Street Address:_______________________________
City:_____________________ State:____ Zip:________
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