PDF - Parkinson's Disease Foundation, Inc.

Make a Donation by Fax or Mail

A gift will help support and promote the highest-quality research world-wide into the cause(s) and cure of Parkinson's disease. To make your gift, please print and fill out this form, then fax it (with your credit card information) to 212.923.4778 or mail it (with your check, money order, or credit card information) to:

Parkinson’s Disease Foundation
1359 Broadway, Suite 1509
New York, NY 10018

Make checks payable to: Parkinson's Disease Foundation

I would like to contribute: ___ $10 ___ $25 ___ $35 ___ $50 ___ $100 ___ $250 ___ Other: ________
Name: ____________________________________________________________
Address: __________________________________________________________
City: ________________________ State/Province: __________ ZIP: ________
Country: _____________________ Email: ________________________________
In Memory Of: ____________________	In Honor Of: _____________________
Other Reason for Donation: ____________________________________________ ___________________________________________________________________
Please send acknowledgement to:
Name: ____________________________________________________________
Address: __________________________________________________________
City: ________________________ State/Province: __________ ZIP: ________

For credit card donations, please provide the following info:
Name on Card: _______________________________________
Credit Card (circle): Visa Mastercard American Express
Card Number: _________________________________
Expiration Date: ______/______ (MM/YY)
Signature: __________________________________________

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