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
Amount of donation: ____________________________
Credit Card Type
(circle one):		 Visa      Mastercard
Card Number: ____________________________
Expiration Date: ____________________________
Please supply your name and address as it appears on your credit card statement.
cure epilepsy cure epilepsy
Full Name: ____________________________
Amount of donation: ____________________________
Address Line 1: ____________________________
Address Line 2: ____________________________
City: ____________________________
State: ____________________________
Postal Code: ____________________________
Province: ____________________________
Country: ____________________________
Email Address: ____________________________
Phone Number:
(optional)		 ____________________________

Send via Postal Mail to:
Citizens United for Research in Epilepsy
730 N. Franklin St. Suite 404
Chicago, IL, 60610		   Fax to:
(312) 255-1809