Please print this form and send it along with your donation to:
dammad DONATIONS
P.O. Box 7281
Gilford ,New Hampshire 03247

First Name:_____________________________________________________________

Last Name:_____________________________________________________________

Email (optional):________________________________________________________

Organization Name:____________________________________________________

Address:________________________________________________________________

City:___________________________________________________________________

State:__________________________________________

Postal Code/ Zip: ________________________________

Phone:________________________________________

Payment Type: (make checks and money orders payable to dammad)
Check Money Order Credit Card (fill out the information below)

Credit Card information

Name (as it appears on the credit card)_________________________________________

Type of card: American Express Visa MasterCard

Credit card number:_________________________

Expiration date:____________________________

Donation Amount: $________________________

Signature: ______________________________________________________________

Do you need a receipt? (If you answer "yes", we will send the receipt to the address listed above unless otherwise noted.) Yes No