Mail-In Donation Form

Print this page, fill in all applicable fields and mail to:

Lymphatic Research Foundation
40 Garvies Point Road, Suite D
Glen Cove, NY 11542

Name	__________________________________________________
Address	__________________________________________________
City	__________________________________________________
State	__________________________________________________
Postal Code	__________________________________________________
Phone Number	__________________________________________________
EMail Address	__________________________________________________

Please accept my donation in the amount of $ _________________________

In honor of

_______________________________________________

In memory of

_______________________________________________

Notify someone of this gift:

Name	__________________________________________________
Address	__________________________________________________
City	__________________________________________________
State	__________________________________________________
Country	__________________________________________________
Postal Code	__________________________________________________
EMail	__________________________________________________

By Check

Make checks payable to: Lymphatic Research Foundation

By Credit Card

Visa _____ Mastercard _____ Am. Express _____
Card Number:	___________________________________
Expiration Date:	___________________________________
Name on card:	___________________________________
Billing address:	___________________________________
	___________________________________

Thank You!