Fax/Mail Donation Form
Please print out this form, fill it out and return via Fax or Postal Mail.
Please make check payable to Citizens United for Research in Epilepsy (CURE)
.
cure epilepsy cure epilepsy
Enter a Gift Amount:
(circle one):
$50     $100    $250    $500    $1000    $2500    $5000
Other Amount: _______________________________________
In Honor or in Memory of: _______________________________________
   
Billing Information
cure epilepsy cure epilepsy
Gift Type: Individual     Corporate      Foundation
Full Name: _______________________________________
Address Line 1: _______________________________________
Address Line 2: _______________________________________
City: _______________________________________
State/Postal Code: _______________________________________
Country: _______________________________________
Email Address: _______________________________________
I would like to receive email updates from CURE: Yes     No
   
Payment Information
cure epilepsy cure epilepsy
Credit Card Type
(circle one):
Visa      Discover     American Express     Mastercard
Card Number: _______________________________________
CVV Number: _______________________________________
Expiration Date: _______________________________________

Send via Postal Mail to:
Citizens United for Research in Epilepsy
223 W. Erie, Suite 2SW
Chicago, IL, 60654
  Fax to:
(312) 255-1809