MSF-USA: Tribute Donation Form

Doctors Without Borders
Tribute Donation Form

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

I am making a tax-deductible gift of $______________

Please charge my gift to: ( ) Visa ( ) MasterCard ( ) American Express ( ) Discover

Account # _________________________________ Exp. Date _______________

Name (as it appears on your card) _______________________________________

Signature _________________________________ Date ___________________

Please make your check payable to Doctors Without Borders and mail it with this form to:

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

This gift is:

in honor of

in memory of

Name _____________________________________________________________

Custom Text ________________________________________________________

Name of person(s) to notify	_____________________________________________
Address	_____________________________________________
City	_______________ State ______ Zip Code ___________

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.