Enclosed is my general contribution in the amount of:  $____________________

Print this page, Fill it out, Mail it to:

Please make checks payable to (do not send cash): 

Parkinson's Network of Arizona,  240  West Thomas Road, Suite 300, Phoenix Arizona  85013-4496.  Phone  480-595-6890   Web site: www.parkinsonaz.org

YOUR NAME______________________________________________________________________

ADDRESS_________________________________________________________________________

CITY________________________________STATE______________________ZIP______________

TEL________________________________________FAX___________________________________

E-MAIL____________________________________________________________________________

This is a gift in Loving Memory Of:  _______________________________________________

This is a gift in Honor of:  _______________________________________________________

 

Please send an acknowledgement card of my donation to (Honoree or Family of deceased):

NAME______________________________________________________________________________

ADDRESS___________________________________________________________________________

CITY__________________________________STATE__________________ZIP__________________

Parkinson's Network of Arizona  is a 501 (c)(3) non-profit organization.  Contributions are tax-deductible.