Federal Tax ID# 20-1803239
To get your 2011 DVD gift set when you contribute $50.00 (Domestically in the USA) or
$60.00 (Internationally)
Fill in this form and Submit it so we can send your DVD copy to you as soon as possible
After you have submitted this form you may select from several methods of payment:
Donor’s Name:
Donor’s Phone:
Donor’s E-mail:
Check the Contact Me box (below)
IF:
You do not want to pay on line by credit card and want us to call you to take your credit card payment on the phone. We will then arrange a time that we will call.
You wish to order a quantity of DVD sets.
Otherwise just leave the Don’t Contact Me box checked
Contact Me
Don’t Contact Me
Ship to Name:
Address
Address 2
City
State
Country:
Zip or Postal Code
PRINT A COPY OF THIS FORM FOR YOUR RECORDS and then Click the Submit Button below to send your order directly to us via the Internet
Copyright © 2011 - The Corneal Dystrophy Foundation.