TO DONATE:

Please complete and print out the following form, and fax it to
Lisa Martin at (516) 944-5399:

Name on Card: ___________________________________

Billing Address: ___________________________________
__________________________________________________

Billing Phone Number: ________________________________

Type of Card: (Circle one:)
VISA | MASTERCARD | AMERICAN EXPRESS

Card Number: _____________________________________

Expiration Date: ___________________________________

Amount of your donation: ____________________________

Your Signature: ________________________

Today's Date: ___________________