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 MEMORIAL AND TRIBUTE CONTRIBUTION FORM

You may honor the memory of a loved one or celebrate the accomplishments of a friend or family member by making a memorial/tribute donation to Prevent Blindness America. A card will be sent to your honoree or his/her family acknowledging your thoughtfulness.

Donor's name:  ______________________________________

Address: ___________________________________________

             ___________________________________________

City: _____________________________________

State and Zip: ___________________

Country: _____________________________________

Honoree's name ____________________________________

____In memory of.

In tribute on the occasion of________________________________

Send acknowledgment card to_______________________________

Address: ____________________________________________

             ____________________________________________

City: _____________________________________

State and Zip: ___________________

Country: _____________________________________

Amount of contribution $___________ ($10 minimum)

____ Check enclosed.

Charge my credit card.
(Credit card donations may be faxed to Prevent Blindness America at 1-312-363-6052)

Credit card Type:
____ Visa
____ Master Card

Expiration date ____________
Credit card # __________________________
Cardholder phone: (_______)______________

Please send to:

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