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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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