Please print, complete and return this form to contribute.

Foundation of NYS Nurses 10 Million by 2010 Campaign
Honoring Our Past-Preserving Our Future

      
        I am honored to become a member of the 2,000 Nightingales with my donation of $5,000 or
        more.
       
       I am unable to offer $5,000 at this time, but would like to help the Foundation reach its goal. 
       Please accept my donation of ______________.
      
        I wish to include the Foundation in my will or living trust.  Please send information.

EVERY donation is deeply appreciated.

NAME ___________________________________________

ADDRESS ________________________________________

CITY___________________ STATE ______ ZIP _________

PHONE (home) _______________ (work) _______________

Please choose one of the following payment options:

(1)        Charge my VISA or Mastercard in the amount of: $__________
            
             Charge my VISA or Mastercard in 5 yearly payments from 2006-2010 (this option is for those
             pledging $5,000 or more only): $__________

Visa Acct. # __________________________________  Exp. Date _________

Mastercard Acct. # _____________________________  Exp. Date _________

Signature _______________________________________

      I will send my check for $___________ annually.

(2)      I have enclosed a check in the amount of: $____________

Please make your check payable to: Foundation of NYS Nurses, Inc.

Mail to: Foundation of NYS Nurses, Inc., VMD Center for Nursing
             2113 Western Ave., Suite 1
             Guilderland, NY 12084-9559
            
If you have questions:  Phone: (518) 456-7858
                                  Email: mail@foundationnysnurses.org
            

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