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Please find enclosed a contribution in the amount of:
(check one)
$200 $100 $25 $10
Other $ __________________
($25 and up recieve commemorative
Hat.)
Name___________________________________________________________________
My Company will match My contribution______________
Address________________________________________________________________
City_____________________________________
State_____________________Zip__________________
Phone #(_______)___________—__________________
My check for $_________________________is enclosed.
Please charge $_________________________to my credit card.
VISA MC AmEx
Credit Card #_____________________________________
Expiration Date__________________
Signature______________________________________________________________
Mail to; Muscular Dystrophy
Assn., INC.
Century II Office Building
1415 28th Street #175
West Des Moines,IA 50266
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