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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]
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