DONATION FORM
Sunday, May 3, 2015 – Komen North Jersey Race for the Cure®
Essex County South Mountain Recreation Complex
West Orange, New Jersey - www.komennorthjersey.org/race
______________________________________________________________________
Send your tax-deductible donation along with this form to:
Susan G. Komen North Jersey • 44 Middle Avenue, 2nd Fl., Summit, New Jersey 07901
For every donation to the North Jersey Affiliate of Susan G. Komen, 75% stays in our community to support local community health
programs that focus on screening, treatment assistance and education and outreach. The additional 25% supports the Komen Award and
Research Grant Program, which funds groundbreaking breast cancer research.
RACE PARTICIPANT INFORMATION
Participant Name: _________________________________________________________ Race Team: ________________________
Donor Name: _____________________________________________________________________ Phone: ____________________
Address: ___________________________________________________________________________________________________
Email: _______________________________________________________________________
MY DONATION IS IN HONOR/MEMORY OF SOMEONE SPECIAL
Please send a tribute card to the following family:
In Honor / Memory of (please circle one): _________________________________________
Family to Acknowledge: _______________________________________________________
Address: _________________________City______________ State ______ Zip__________
CORPORATE MATCHING GIFTS
Did you know that you could double your donation through a corporate matching gift program? Check with your company to complete
your Corporate Matching Gift documents and mail them to our office.
CASH DONATION
____ Enclosed is my check. Please make check payable to Susan G. Komen North Jersey
CREDIT CARD PAYMENT AND BILLING INFORMATION
____ Circle one company: AMEX
MasterCard
VISA
DISCOVER
Signature:
Credit Card #: _____________________________Exp. Date:_________ SS Code:__________________________________
Address: ________________________City______________ State ___ Zip______
GIFT RECOGNITION ON OUR 2013 RACE FOR THE CURE WEBSITE.
___ Make this an anonymous gift
____ Display the amount of my donation publicly
Recognition Name: ___________________________________________________________________________________________
This will be used for public recognition (John Smith or The Smith Family)
Race Hotline: (908) 277-2904 | [email protected]