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Thursday, August 28, 2008
Adopt-A-Journal Participation Form



Personal Information
Name:
Address:
City:   
State:
Zip Code:
Day Time Phone:
E-mail:
Donation Information
I would like my donation to be applied to one of the following:
(Select one of the following options)
Donation to the general fund
Support a specific field of interest:
Subscribe to a specific journal:
Have a staff member contact me regarding a selection
Payment Information
The amount of donation or subscription price:   $
Payment by: Credit Card    Please bill me
Credit Card:   Visa    MasterCard    American Express
Card Number:
Expiration Date: (mm/yyyy)
Your Name as it Appears on the Card:

I would like an email copy of this request (if yes, be sure to include your e-mail address above):
          Yes   No

 

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