LDA-CA Donation Form

Contact Information
Name____________________________________________________________________________

Address_________________________________________________________________________

City/State__________________________  Zip_________  E-Mail______________________

Home Phone__________________  Work Phone__________________  Fax_________________



Donation Type
ONE-TIME DONATION:   I would like to make a one-time donation of  $_____________

MONTHLY DONATION:    (Credit card only)  I would like to make a monthly donation
                     of $_____________.  Please bill my credit card on the _____
                     day of each month.

QUARTERLY DONATION:  (Credit card only)   I  would  like  to  make  a  quarterly
                     donation of $_____________.  Please  bill  my  credit  card
                     quarterly beginning on the following date: ________________
					 


Credit Card Information
Card Type:     ____MasterCard     ____Visa

Account Number___________________________________ Expiration______________

Account Name____________________________ Signaure_________________________



Sending Options
FAX with Credit Card information or mail with Check or Credit Card information:

         LDA-CA
         P.O. Box 601067                          FAX 916-725-8786
         Sacramento, CA 95860