By: By:
Name: Name:
Title: Title:
Date: Date:
Name:
__________________________________________
Company Name:
__________________________________________
Street:
__________________________________________
City:
__________________________________________
State or ____________________________
Province: (For US and Canada residents only)
Zip/Postal Code:
_____________________________
Country:
_____________________________
Phone:
_____________________________
E-mail:
_____________________________
Fax:
_____________________________
Representatives Information
(Name and e-mail of person(s) who will be the point of contact between your organization and the Foundation)
Members should deliver a check for the Initial Fee to the address set forth in Paragraph 7 of this
Agreement. Members will receive a reminder for subsequent donations as annually.