Please print this form, complete it and mail it, along with your credit card information, to: Population Reference Bureau P.O. Box 96152 Washington, D.C. 20009-6152
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Contact Information |
Prefix: |
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First Name: |
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Middle Init.: |
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Last Name: |
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Home Phone: |
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Work Phone: |
__________________________________ |
E-mail: |
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Address: |
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City: |
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State: |
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Country: |
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Postal Code: |
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Optional |
My donation is in honor of: |
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My donation is in memory of: |
__________________________________ |
Please notify the following person(s) of this gift:
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Name: |
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Address: |
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City: |
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State: |
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Country: |
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Postal Code: |
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Payment Information |
Please accept my gift of: |
__$1,000 __$500 __$250 __$100 __$50 __$35 __Other $______ |
Credit Card: |
__ MasterCard __ Visa __ American Express |
Name on Card: |
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Card #: |
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Exp. Date: |
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Signature: |
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I understand that I may increase, decrease, or suspend this contribution pledge at any time for any reason.