DONATION FORM

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I want to help Missouri Protection & Advocacy Services in advancing the rights of persons with disabilities in Missouri with my donation of:

_______$25.00 ________ $50.00 _________ $100.00 _________ Other $_________

__________ Check Enclosed

In Honor/Memory of: _________________________________________________________

Donation to be applied to the following program(s) (Circle):

PADD  CAP  PAIMI  PAIR  PAAT  PABSS  PATBI  PAVA  WIPA  ALL PROGRAMS

Signature X _________________________________________________________

NAME: ____________________________________________________________

ADDRESS: _________________________________________________________

CITY: ______________________________ STATE: ________________ ZIP: _________

PHONE: ___________________________ E-MAIL: _____________________________

Donations may be made in person or mailed with a copy of this form to:

Missouri Protection & Advocacy Services
925 South Country Club Drive
Jefferson City, Missouri 65109

You will receive an acknowledgement in the mail.

Thank you for your support of our work!

 

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