Title: ___________      Name: ______________________________________________________

 

Address: ______________________________________________________________________

 

Address 2: ____________________________________________________________________

 

City_______________________________State:_______________Zip:____________________

 

Phone Number: (______) _________________________________________________________

 

Email Address: _________________________________________________________________

 

  I would like to give a monthly gift of:

          ⇒  $50 - Includes free membership - effective after four consecutive months of donation

 

          ⇒  $30 - Includes free membership - effective after four consecutive months of donation

 

          ⇒ $15

 

          ⇒ $20

 

          ⇒ Other _____________

 

  Payment Method:

 

          ⇒  Visa              ⇒   MasterCard                ⇒  American Express                  ⇒  Discover

 

Expiration Date: ________/_________ 

3 or 4-digit security code ____________ (located on the front or back of card)

Signature: _____________________________________________________________________ 

Please send form to:
American Association of Kidney Patients
3505 E. Frontage Rd, Ste 315
Tampa, FL 33607
 _{*This donation will repeat on a monthly reccurance.  
**Payments will be processed on the 15th of each month.}