This form will be replaced by our new electronic form by March 1, 2004.

MAKE A GIFT TO THE FOUNDATION

Print out this form now, and mail it in with your tax-deductible gift. Thank you for caring!


The Foundation is a 501C3 tax-exempt, non-profit group.

Please PRINT this page out, and mail it with your check to:


PO Box 492028 · Los Angeles · California 90049-8028
(310)471-0303 · www.Anti-smoking.org

I want to join or make a gift to the Foundation for a Smokefree America. I wish to support your work preventing teens from starting to smoke, and empowering smokers to quit successfully.

 

First Name __________________________ Initial_____

Last __________________________________________

Company ______________________________________

Street Address _________________________________

______________________________________________

City _________________ State _____ Zip __________

Phone 1 ______________________________________

Phone 2 ______________________________________

Fax __________________________________________

Website (if any)________________________________

email (required if newsletter desired)

______________________________________________

When it starts publication, I ____would ____would not like to recieve your newsletter with news of the Foundation and tobacco news updates. (email address required.)

I understand I may unsubscribe at any time, and that my email, address and phone will never be shared.

Enclosed are my dues for a one-year membership as a —

____ $15 Student

____ $35

____ $50

____ $100

____ $250

____ Other amount

____ I pledge or enclose a gift of $ _______________.

_____I will consider a major gift in the range of __________________. Please have Mr. Reynolds call me to discuss my gift.

Information about the Foundation's
programs and mission is posted at:
www.anti-smoking.org/info.

Your gift is tax-deductible. The Foundation is a 501C3 tax-exempt, non-profit group.

Please mail the printout of this page with your check to:



PO Box 492028 · Los Angeles · California 90049-8028
(310)471-0303 · www.Anti-smoking.org

Thank you for your generosity and for caring.