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You may give to the ADI Foundation using your credit card be calling the
ADI Central Office at (419)542-0101
OR complete the form below and mail with check to the address below
Name:_______________________________________Date:_________________
Address:____________________________________________________________
______________________________________________________________
______________________________________________________________
Phone:___________________________ Fax: _______________________________
E-mail: ___________________________
Check one:
Total donation enclosed: $__________________
Yearly or monthly donations: $ ______________
Time period: ___________________________________
Remembrance gift: $ _________________________
for: ______________________________________________
____________________________________________________ __________________________________________________
Special Instructions: _______________________________________________ ______________________________________________________________
_____________________________________________________________________
(Please make checks payable to ADI Foundation)
A more detailed account of ADI Foundation activities is available from the central office.
All contributions to the Foundation are fully tax deductible under USA IRS tax code.
All other countries; please check your country's tax code.
A receipt will be issued
for all gifts as required by law.
Affiliate Member of the FÉDÉRATION DENTAIRE INTERNATIONALE
Associate Member of HEALTH VOLUNTEERS OVERSEAS
"World Understanding --- through Education"
Academy
of Dentistry International Foundation
3813 Gordon Creek Drive
Hicksville, Ohio 43526
- USA
Tel: (419) 542-0101 Fax: (419) 542-6883
email: rramus@bright.net
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ADI Foundation: Commitment Form 
