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
|*Type of Card:||Visa Mastercard Discover American Express|
|*Card Number:||*Exp: (mm/yy)|
|*Name on Card:|
|Donor Name:||(eg, Mr. Tom Jones)|
|*E-Mail:||(for confirmation only)|
HONOREE INFORMATION (optional)
This gift is made in honor of ...
|Notify Others of Gift*|
|*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.|
May we add you to our mailing list?
May we contact you by e-mail?
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)|
|E-Mail:||(for emailing list)|
Thank you for your donation.