Brain Injury Association of Wyoming DONATION FORM

Please print this page, fill it out, and mail it to us (contact info below)

Type of Donation, and value

Cash____________________

Check___________________

Money Order______________

In-Kind Donation___________

(merchandise, services, library materials, supplies etc.)

Comments: ________________________________________________________________

________________________________________________________________

Contact Information

Name:

 ________________________________

Address:

 ________________________________

City:

 ________________________________

State:

 ____

Zipcode:

 _________________

Telephone:

 ________________________________

Best time to call:

 _________________

E-mail:

 ________________________________

Brain Injury Association of Wyoming
111 West 2nd Street, Suite 106
Casper, Wyoming 82601   1-800-643-6457  Fax (307)237-5222

Your donation is considered a charitable contribution.
Our tax ID number is available upon request.