Hope for a Cure Foundation
Donation Form

Please PRINT, fill out, and mail this form to the address below.

1. Donor Information:

   Name (Dr. Mr. Mrs. Ms.): ____________________________________________________

   Address: __________________________________________________________________

   City: _____________________________________ State: ________ Zip:_______________

   E-mail*: ___________________________________________________________________

   Phone*: Day (____)____________ Evening (____)____________ Cell (____)____________
   *Phone and e-mail optional.

2. Donation Amount: $________________________________________________________

3. In Memory Of: _____________________________________________________________

   OR

   In Honor Of: _______________________________________________________________

4. PLEASE notify the following people of my donation:

   Name (Dr. Mr. Mrs. Ms.): _____________________________________________________

   Address: __________________________________________________________________

   City: _____________________________________ State: ________ Zip:_______________

5. May we mention your name on our web site as donor or corporate
   sponsor?     Yes     No

   Do you have a title ( Example: Dr., Esq.) would you like us to include? _______________

   If you are a corporate partner, may we use your logo and would you like a link
   to your web site?     Yes     No

6. Make checks payable to: Hope for a Cure Foundation