Tribute Gift Donation Form

INSTRUCTIONS

  1. Please fill out one form for each person you wish to honor.
  2. Send the form and your check or credit card information well ahead of when you wish your friend or family member to receive the Tribute Gift Card.
  3. Make the check (tax deductible) payable to ThyCa, in U.S. dollars.
  4. There are two ways to send your request. You may mail the form below with your check or credit card information to ThyCa Tribute Gift Card, P.O. Box 1102, Olney, MD 20830-1102 Or you may mail just the check or credit card information, and e-mail the form to Tribute-gift@thyca.org.

DONOR INFORMATION

1. Title (Mr., Mrs., Ms., Miss, Dr., etc.) _______________________________________________

2. First Name ____________________________________________________________________

3. Last Name ____________________________________________________________________

4. Mailing Address _______________________________________________________________

5. City _________________________________________________________________________

6. State/Province ________________________________

7. Zip/Postal Code _______________________________

8. Country ______________________________________

9. Preferred Phone _______________________________

10. E-mail address ______________________________________________________________

TRIBUTE CARD INFORMATION

Please complete ALL of the information below.

11. This tribute card is:

In Memory of ___________________________________________________________________

OR

This tribute card is for a Special Occasion honoring:____________________________________

Birth__ Birthday__ Anniversary__ Wedding__ Graduation__ Other____

OR

This tribute card is Wishing a Speedy Recovery to: ___________________________________

12. a. Name of person card is being sent to: ____________________________________________

(if In Memory of, please note relationship here)_____________________________________

Complete address for recipient of card:

b. Address: ___________________________________________________________________

c. City: _______________________________________________________________________

d. State/Province: ______________________________________________________________

e. Zip/Postal Code: _____________________________________________________________

f. Country: ____________________________________________________________________

DONATION INFORMATION

Enclosed is my tax-deductible donation check to ThyCa in U.S. dollars for:

__$5 __$10 __$25 __$50 __$100 __ $500 __Other $______________

___ Please charge my __Visa ___Mastercard

Card# ___________________________________Exp__________

Name as it appears on the Card____________________________

Signature______________________________________________

Thank you for your donation to ThyCa. Please note: ThyCa: Thyroid Cancer Survivors’ Association, Inc.SM, DOES NOT release to other organizations the names and addresses of its contributors.