ICCD Donor Form

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ICCD Donor Form

Please enter the information here then mail your donation to:

The International Center for Clubhouse Development,
425 West 47th Street, New York, New York 10036

Please use the submit button below which will help notify us of your intentions. Thank You.

Please provide the following contact information:
First name
Last name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail
URL
Choose one of the following options:

Friend (Less than $150)
Sponsor ($150-$999)
Patron ($500-$999)
Benefactor ($1,000-Up)

Enter today's date of ... :


How much would you like to donate?

in American Dollars

Enter any comments you would like to make here.


Last revised: May 18, 2001
General ICCD E-mail: ICCDNYC@compuserve.com
The Executive Director of the ICCD is Joel Corcoran  
ICCD Webmaster with questions or comments about this web site.
Copyright © 2001 International Center for Clubhouse Development 
Last modified: May 18, 2001