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How to Donate to
Lupus Alliance - Hudson Valley

Please fill out the following form, and on completion print two copies, one for your records and mail one with your check to:

Lupus Alliance - Hudson Valley
171 East Post Road, Room 218, White Plains, NY 10601

To let us know that your donation is enroute to our office, please also
submit this form after completion and printing.
(these instructions will be repeated for your convenience at the bottom of the form.)

I want to help Hudson Valley Lupus Alliance broaden public awareness of Lupus and educating patients, their families, and members of the community about this serious autoimmune disease. Enclosed is my gift of:

$1000   $250      $100      $50      $25      Other $

(Your gift is tax deductible to the full extent of the law.)

As we would like to thank our supporters publicly, please let us know if it is acceptable to you to:

  Include my name, or I would prefer to remain unlisted 

Enter your Name and Address here
Name   
Number
and Street
City State    Zip
Telephone
(optional)		 Area Code   Number 
E-Mail
(optional) 		  

Please make checks payable to
"Lupus Alliance-Hudson Valley NY Affiliate"

This gift is eligible for a corporate match. I have enclosed the form with my donation.

This gift is In Memory of, or In Honor of

Name   
Number
and Street
City State    Zip

Please notify the following individual(s) of this gift:

Notification One
Name   
Number
and Street
City State    Zip

Notification Two
Name   
Number
and Street
City State    Zip

On behalf of all the Patients and Families of Hudson Valley Lupus Alliance
please accept our sincere gratitude for your kindness.

Final Instructions to complete your Donation

1

On completion of this entire form, please print two copies of it for yourself. One you should retain for your records, and the other please send with your check to

Lupus Alliance-Hudson Valley
PO Box 8240, White Plains, NY 10602

 

2

Then press the "Submit" button to send us a copy of this form too. In this way we will know to expect your contribution by mail.

   

Please be patient, it takes a short time to send the submission.

  
   

  
   
 
 

© 2003 Lupus Alliance-Hudson Valley
PO Box 8240, White Plains, NY 10602

171 East Post Road Room 218, White Plains, NY 10601
(914) 948 - 1032    or   1 (888) 57 LUPUS

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