Donation Form - March Of Dimes

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Donation form
Whether you are a long time March of Dimes supporter or are giving for the first time,
thank you for your commitment to helping babies be born healthy. Please use this form
to mail or fax your donation. If you have a special request, please contact us at
.
Mail or fax your completed form along with your donation to:
March of Dimes
Attention: DRFR
1275 Mamaroneck Avenue
White Plains, New York 10605
Fax: 914-997-4537
(Credit Card only)
Donor information
First Name ____________________________ Last Name ____________________________
Address _____________________________________________________________________
City _________________________________ State _________________________ _ _______
Zip Code _____________________________ Country _______________________________
Phone _______________________________ E-Mail ___________________________ _ _____
Donation
Donation Amount $ ________________
(in US currency)
My check is enclosed
Please charge my credit card
Card Type
Card Number ___________________________ ___ Expiration ________________ _ ________
Name of cardfolder ______________________ ___ Signature ___________________ _ _____
(Please print out the form and sign)
Billing Address: (if different than above)
Address _____________________________________________________________________
City _________________________________ State _________________________ _ _______
Zip Code _____________________________ Country _______________________________
code – 3IN

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