Make an Alzheimer's Donation by Fax or Mail

A gift will help support and promote the highest-quality research world-wide into the cause,

care and cure of Alzheimer's.

To make your gift, call 1-800-259-4636 or please fill out and print this form , then fax it

(with your credit card information) to 212-915-1319. You can also mail the form

(with your check, money order, or credit card information) to:

Fisher Center for Alzheimer's Research Foundation

199 Water Street, 23rd Floor

New York, NY 10038

Make checks payable to: Fisher Center for Alzheimer's Research.

I would like to contribute:

$10		$50		$100
$25		$75		Other $

Donation Details This donation is: In Honor of In Memory of Name If you make a donation on a person's behalf, please provide the address and individual you would like an acknowledgment letter sent to. Name Address City State Zip Code Country Email Address

Payment Information Name Address City State Zip Code Country Email Address Phone For credit card donations, please provide the following info: Name on Card Credit Card Visa Mastercard American Express Discover Card Number CVV Code Expiration Date / (MM/YY) Signature _________________________________________

"Optional Questions" My preferred method of contact is: Email Phone US Mail How did you hear about us? Comments or Suggestions