Print this form, fill it out and mail it with a check or credit card gift.
Do not send credit card information by e-mail. But you can fax the form or send it by
regular mail with a check or credit card gift. For more information,call us at (800) 331-2020.


PREVENT BLINDNESS AMERICA CONTRIBUTION FORM


Name:    ____________________________________________

Address: ____________________________________________

             ____________________________________________

City: _____________________________________

State and Zip: ___________________

Country: _____________________________________

Phone: ____________________ Fax: ___________________

Yes! I want to make a tax deductible contribution. My contribution comes by (please check one):

____ Check to Prevent Blindness America in the amount of $ _______

____ Credit card (By fax or US Post Office Only. Fax: 1-312-363-6052) Amount  $ _______

Credit card Type:
____ Visa
____ Master Card

Enter your card number here: ________________________________

Expiration date: ___________________________________________

Signature: ________________________________________________

____ Yes! Send me information on other giving programs.

____ Call me to discuss a gift to support the work of Prevent Blindness.

Please send to:

Prevent Blindness America
211 West Wacker Drive
Suite 1700
Chicago, Illinois 60606