| Fund |
Gift Amount |
| General Fund (Unrestricted Gift) |
$
|
| 2010 Scholarship Campaign |
$
|
| TJ's Fund for Eating Disorders Research |
$
|
| Research Support |
$
|
| Advocacy |
$
|
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| Mailing
Address: Please provide
your mailing address to receive a written receipt. |
| First Name* |
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| Last Name* |
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| Address* |
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| City* |
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| State/Province* |
Outside North America - Choose 'Unlisted' from the drop-down menu |
| Zip/Postal Code* |
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| Country* |
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| Telephone* |
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| E-Mail* |
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Are you a member of the Academy for
Eating Disorders?
Yes
No |
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| If applicable, please indicate the following: |
| My gift is in honor of |
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| Please send an acknowledgement card to: |
| Name |
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| Address |
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| City |
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| State |
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| Postal Code |
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| Country |
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Please contact me regarding:
Other forms of giving (stocks, securities, insurance, matching
funds, etc.) |
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I would like my contribution to
remain anonymous
Yes
No |
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| Payment |
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American Express |
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VISA |
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MasterCard |
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| Card Number* |
Numeric only, no spaces or dashes |
Card Security Code:* what is this? |
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| Expiration Date* |
Month
Year
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| First Name* |
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| Last Name* |
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| Billing Address* |
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| Billing City* |
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| Billing State* |
Outside North America - Choose 'Unlisted' from the drop-down menu |
| Billing Postal Code* |
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Country*
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