MSF-USA: Tribute Donation Form

Doctors Without Borders
Tribute Donation Form

Name	________________________________________
Address	________________________________________
City	_______________ State _____ Zip Code ___________
Telephone Number	________________________________________
Email Address	________________________________________

I am making a tax-deductible gift of $______________

Please charge my gift to: ( ) Visa ( ) MasterCard ( ) American Express ( ) Discover

Account # _________________________________ Exp. Date _______________

Name (as it appears on your card) _______________________________________

Signature _________________________________ Date ___________________

Please make your check payable to Doctors Without Borders and mail it with this form to:

Doctors Without Borders USA, P.O. Box 5030, Hagerstown, MD 21741-5030.

This gift is:

in honor of

in memory of

Name _____________________________________________________________

Custom Text ________________________________________________________

Name of person(s) to notify	_____________________________________________
Address	_____________________________________________
City	_______________ State ______ Zip Code ___________

What inspired you to make a donation today? (Please check only one answer.)
(9) ____ Internet Fundraiser (not MSF affiliated) (C) ____ Other Fundraiser (J) ____ Word of Mouth (2) ____ MSF Mailing (E) ____ Special Occasion (e.g. holiday, birthday) (D) ____ Tribute (6) ____ MSF Website (G) ____ TV/Film/Radio (A) ____ Other Website	(F) ____ Print (Newspaper, Magazine, etc.) (H) ____ World Events (4) ____ MSF Event (7) ____ MSF Toll-Free Number (3) ____ MSF Phone Solicitation (5) ____ MSF Advertisement (8) ____ MSF Office Staff Interaction Other__________________________

Thank you for your generosity. All contributions are tax deductible. Doctors Without Borders USA, Inc. is recognized as tax exempt under section 501(c)(3) of the Internal Revenue Code, Tax ID # 13-3433452.

AUU080000DM