Alzheimer's Services of Northern Indiana, Inc.
On-Line Donation Form
 
Please print, complete and mail in this form with your donation to:
922 E Colfax Ave; South Bend, Indiana  46617

Yes, I wish to help those of the Northern Indiana area impacted by Alzheimer's disease.
______ $25 ______ $50 ______ $75 ______ $120 ______ $200 ______
Other $_____
 
From: (your information)
 
Name:______________________________________________

Address:____________________________________________

City/State/Zip:_______________________________________

Phone (eve):______________ Phone (day):_______________
 

Thank you for caring.
Please make your check payable to the Alzheimer's Services. Your gift is tax deductible.
 
 
This gift is made in memory/honor of:
 
Name:______________________________________________

Please notify:

Name:______________________________________________

Address:____________________________________________

City/State/Zip:_______________________________________
 

Please charge my VISA or MasterCard:

Account number:_____________________________________

Expiration date:________________

Signature (required for charges):___________________________

 
If you have any questions, please call (888-303-0180) or e-mail the
Alzheimer's Services of Northern Indiana, Inc.