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Donation Form
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Gift from the Heart to Duchenne Muscular Dystrophy Research Fund (DMDfund)
(To print this form, only, click on the text and then use your normal print options)
Please print and use this form for contributions, memorial gifts, or for honoring your friends
and family on special occasions. A beautiful card will be sent to them in your name.
All contributions are tax-deductible as allowed by law.
Once completed, mail this form and and donation gift to:
DMDfund • PO Box 17371 • Encino, CA 91416
Please accept my tax deductible contribution of $___________
___ Check Enclosed
(Please make payable to "DMDfund". )
___ VISA or ___ MasterCard
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| exp. ___/___
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Signature (as it appears on your credit card)
Your Name: ___________________________________________________________
Address: _____________________________________________________________
City: ____________________________ State __________ Zip __________
E-mail Address: _____________________________________________ (To be held in privacy)
My gift is made: in memory of: _________________________________________________________
in honor of: _________________________ for the occasion of ________________________________
____________________________________________________________________________________
Please Notify :
Name _____________________________________________
Address ___________________________________________
City _____________________________ State ____________ Zip __________
|___| I've enclosed my statement of sentiment and support for the kids & families with DMD.
You have my permission to include these in the DMDfund website Hearts of Gold register.
Please send me a link at ____________________________________ (address will be held in privacy)
...We thank you for your generosity... and for remembering... your heart is a muscle too!
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