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You may make a donation by printing this form, completing the information and mailing or faxing the form to:

United Spinal Association
54 Nashua Street
Milford, New Hampshire 03055-3717
FAX: (603) 672-6027
PH: (800) 786-8022

DONATION and CREDIT CARD INFORMATION * Denotes required fields.
The following information must be completed to fulfill your credit card donation:

*Is this your first donation to our organization?   Yes  No
*Amount of contribution: $25   $50   $100   $250   Other:
Contribution Frequency: One Time  Monthly  Quarterly  Annually

**By selecting this option, you agree to allow this non-profit organization to charge your credit card the amount listed above at the selected frequency. To discontinue, contact the United Spinal Association in writing with your instructions.

*Type of Card:	Visa Mastercard Discover American Express
*Card Number:	Exp: (mm/yy)*
*Name on Card:
Donor Name:	(eg, Mr. Tom Jones)
*Address:
*City:	State: Zip:
*E-Mail:	(for confirmation only)
Phone:
HONOREE INFORMATION (optional) This gift is made in honor of ...
Honoree:
Notify Others of Gift*
Name:
Address:
Address:
City:	State: Zip:
E-mail:
*If you would like us to inform others of the gift you've made on behalf of the honoree, please enter the name(s) and mailing address(es) in the form.

MAILING/SHIPPING INFORMATION
May we add you to our mailing list? Yes No		May we contact you by e-mail? Yes No

If your mailing address for gifts and/or e-mail contact is different from your billing address listed above, please complete the following:

Name:	(eg, Mr. John James)
Address:
City:	State: Zip:
E-Mail:	(for emailing list)

Thank you for your donation.

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