BIA-Hi Donation Form
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NAME___________________________________________________________

TITLE___________________________________________________________

COMPANY_______________________________________________________

ADDRESS________________________________________________________

________________________________________________________________

CITY ________________________________STATE_________________

ZIP__________________________

TELEPHONE (home)____________________

(business)___________________ (fax)______________________

EMAIL ________________________________________________________________

NOTES (Reasons for giving or in memory of . . .):

________________________________________________________________

________________________________________________________________

GIFT/PLEDGE INFORMATION

Yes, I (we) want to make a gift to Brain Injury Association of Hawaii this year of $______________________

__ Gift enclosed $________________

__ Gift pledged $_________________ Please bill me

beginning _____________

and thereafter __ monthly __ quarterly __ yearly __ other_______________

My gift will be matched by_________________________________________ company/foundation/family.

__ Form enclosed __ Form will be forwarded

Please send this form with your check to:

BIA Hawaii
420 Kuwili Street, Suite 103
Honolulu, Hawaii 96817

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