MSF-USA: Form to Make a Donation by Mail

Doctors Without Borders
Field Partners Monthly Giving Enrollment Form

Name	________________________________________
Address	________________________________________
City	_______________ State _____ Zip Code ___________
Telephone Number	________________________________________
Email Address	________________________________________

I want to become a Field Partner and help Doctors Without Borders volunteers bring medical care to victims of wars, natural disasters, and epidemics every day through a monthly gift. I would like to make an automatic monthly gift of $______________

Please charge my gift each month to: ( ) Visa ( ) MasterCard ( ) Amex ( ) Discover

Account # _________________________________ Exp. Date _______________

Name (as it appears on your card) _______________________________________

Signature _________________________________ Date ___________________

If you would like to pay by direct debit from your checking account each month, please send a voided check, together with this form to:

Doctors Without Borders USA, P.O. Box 5030, Hagerstown, MD 21741-5030.

Signature _________________________________ Date ___________________

Thank you for your generosity. All contributions are tax deductible. Doctors Without Borders USA, Inc. is recognized as tax exempt under section 501(c)(3) of the Internal Revenue Code, Tax ID # 13-3433452.