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| 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). |
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| Amount of
donation: (circle one): |
$5k $1k $500 $250 $100 $50 Other: |
| In Honor or in Memory of: | _______________________________________ |
| Please list the person who you wish to be notified of this donation: |
_______________________________________ |
| Recipient Address: | _______________________________________ |
| Credit Card Type (circle one): |
Visa Mastercard American Express Discover |
| Card Number: | _______________________________________ |
| Expiration Date: | _______________________________________ |
| CVV Number: | _______________________________________ |
| Please supply your name and address as it appears on your credit card statement. |
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| Full Name: | _______________________________________ |
| Amount of donation: | _______________________________________ |
| Address Line 1: | _______________________________________ |
| Address Line 2: | _______________________________________ |
| City: | _______________________________________ |
| State/Postal Code: | _______________________________________ |
| Province: | _______________________________________ |
| Country: | _______________________________________ |
| Email Address: | _______________________________________ |
| Phone Number: (optional) |
_______________________________________ |
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