MSF-USA: Form to Make a Donation by Mail

Doctors Without Borders
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.

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.