Your name _________________________________ Donation Amount $ _________________
Business Name (if applicable) ____________________________________________________
Mailing address ____________________________ City/State/Zip _______________________
Email address ______________ Phone number ________________ Fax number ____________
[ ] I/we want to donate by credit card # ____________________________ Exp. Date ________
Name on card (please print) _________________________ Type of card [ ] MC [ ] VISA [ ] AE
Signature_______________________________________
I/we would like to designate our gift to:
[ ] Where needed [ ] Research [ ] General operations [ ] Education
[ ] Building [ ] Equipment [ ] Endowment [ ] Other ________________
Fax to: (805) 682-3332 (no cover sheet is necessary) or mail to the above address.
Thank you for your support of Sansum Diabetes Research Institute!
Please call Susan Murray, Communications and Database Manager, at (805) 682-7638, if you have any questions, want additional information, or would like to arrange a tour of the Institute. You may also email to: development@sansum.org
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