DONATION FORM FOR EACH $25.00 DONATION YOU WILL

DONATION FORM
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FOR EACH $25.00 DONATION YOU WILL RECEIVE A COPY OF
“PAINLESS PUZZLES OF THE ACROSTIC KIND”
VOLUME(S) 1 AND/OR 2
AS A TOKEN OF OUR APPRECIATION.
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By credit card on-line through Paypal.
By check mailed to Pain Connection with completed form.
Fax your completed order form and credit card information to 301-231-6668
Through Network For Good and www.Razoo.com which are secure services.
Name: ______________________________________________________________________________
Address: _______________________________________________________________________________
City, State, Zip: __________________________________________________________________________
Work phone: ________________________________
Home phone: ______________________________
E-mail:______________________________
Volume 1:____ Volume 2:____
Credit Card Number: __________________________________________
Expiration Date: _______
500__ $1000__ $_______
Circle one:
VISA
/
3 Digit security #:_________Donation:
MASTERCARD
/
DISCOVER
/
$25__ $50__ $100__ $250__
AMERICAN EXPRESS
Signature:__________________________________________________
I would like to make a donation for a Dedication on behalf of or in memory of another person. Please
enter the person's name: ________________________________________________________________
*A copy of the latest Financial Report filed by this organization may be obtained by contacting the above
address, or by contacting the state agency of Maryland: Office of the Secretary of State, State House,
Annapolis, MD 21401. Registration by the state does not imply endorsement.
Your name will be kept confidential. Pain Connection does not sell or disseminate its donors' names under
any circumstance.
12320 Parklawn Drive, Rockville, Maryland 20852
tel. 301-231-0008 ! fax. 301-231-6668
http://painconnection.org