“Give a Dam for Chuck”
Donation Form


Please find enclosed a contribution in the amount of:
(check one)


$200 $100 $25 $10 Other $ __________________
($25 and up recieve commemorative Hat.)

Name___________________________________________________________________

My Company will match My contribution
______________

Address________________________________________________________________

City_____________________________________

State_____________________Zip__________________

Phone #(_______)___________—__________________

My check for $_________________________is enclosed.

Please charge $_________________________to my credit card.

VISA MC AmEx

Credit Card #_____________________________________

Expiration Date__________________

Signature______________________________________________________________

Mail to; Muscular Dystrophy Assn., INC.
Century II Office Building
1415 28th Street #175
West Des Moines,IA 50266

 

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