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Capital Campaign For The New Headquarters

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					                                   APHA Credit Card Payment Form
                                                       (Please print or type)

Fax to (202) 777-2534 or mail to: APHA, 800 I Street, NW, Washington, DC 20001

                                                                                 Date:

Credit Card Payment for: Donation to Gerontological Health Section Endowment Fund
(Please provide description)

Please apply funds to: (CHECK ONE)
       □ Weiler Leadership Award (#390023)
       □ Rural Health Research Award (#390032)
       □ International Research Award (#390020)
       □ Student Awards (#390024)
       □ Other (#328063)

Credit Card Type:               Visa               MasterCard             American Express
    (please check one)


Card # __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __                                   Exp Date:          /
                                                                                                     (month/year)

Name on Credit Card:

Signature:

Please charge my credit care for (amount): $


Please mail copy of receipt to individual below:

Name:

Address:

City:                                                             State:                        Zip:

Phone:                                                            Fax:



Other:


                         APHA is classified by the IRS as a non-profit 501(c)(3) organization.
                             Gifts are tax-deductible to the full extent allowed by law.

				
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