Please print this form and send it with a check or your credit card information to:

Cancer research Foundation
P.O. Box 124
South Salem, N.Y. 10590

(Please do not send cash in the mail.)

If your employer has a matching gifts program, you may have an opportunity to double your gift.

About You:

Name: ________________________________

Company: _____________________________

Address: ______________________________

City: _________________ State: ___________ Zip Code: ________

Telephone: _______________

Enclosed is my donation of:

While we encourage donations in the following amounts, we will gratefully accept a gift of any size.

$100 $300 $500 Other $_______________

1. Enclosed is my check in the amount of $ _________
2. Please charge my credit card in the amount of $ __________

Visa MasterCard

Card Number: ___________________ Expiration Date: ________

Thank you very much for your support. Your gift will help us find cures for Kidney Cancer, Breast Cancer, Leukemia, Lymphoma, Multiple Myeloma and Myelodysplasia, and improve the quality of life for patients and their families.