RIDE TO CURE DIABETES PLEDGE FORM |
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| Sponsor Name: | ||
| Address: | ||
| City: | State: | Zip: |
| Daytime Phone: | ||
| Evening Phone: | ||
| email: | ||
| Donation Amount (please circle or write in): $25 $50 $100 $250 $__________ | ||
| This pledge is in the name of (Circle One):
Team Chad & Dad (Chad and Charlie Lawrence)
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| Credit Card Information (if you want to charge this donation to your charge card):
Card Number _________ - _________ - _________ - _________ Exp. Date MO___ YR_______ Discover American Express VISA Master Card
Signature:___________________________________________________________ | ||
Mail this form with your donation to:
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