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| Please
print this form, fill it out, and send along with your donation
to:
Muscular Dystrophy Association — WEB
P. O. Box Jerry
Phoenix, AZ 85062-1111 |
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| Your First & Last
Name: |
______________________________________ |
| Address: |
______________________________________ |
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______________________________________ |
| City, State, Zip: |
______________________________________ |
Country
(if outside U.S.A.): |
______________________________________ |
| E-Mail address: |
______________________________________ |
| Daytime Phone: |
(____)______________________ |
| Evening Phone: |
(____)______________________ |
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Send me e-mail updates on MDA research progress and events. |
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| Your support will help MDA continue its research and service programs for 40 different diseases. Or, you can specify a specific program or
disease here: |
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If you would you like this gift to be a tribute, please answer the following:
To have notification card(s) sent, please complete the following.
I would like a notification card without the gift amount mailed to:
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______________________________________ |
| From (Your name as you would like it to appear on the card): |
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I would like a second notification card without the gift amount mailed to:
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| City, State, Zip: |
______________________________________ |
| Country (if outside U.S.A.): |
______________________________________ |
| From (Your name as you would like it to appear on the card): |
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