|
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 the Foundation activities is available from the central office.
Contributions should be made out to: ADI FOUNDATION.
All contributions to the Foundation are fully tax deductible. A receipt will be issued
for all gifts as required by law.
Affiliate Member of the FÉDÉRATION DENTAIRE INTERNATIONALE and Associate Member of HEALTH VOLUNTEERS OVERSEAS
"World Understanding --- through Education"
Academy
of Dentistry International Foundation
PO Box 307
Hicksville, Ohio 43526
- USA
Tel: (419) 542-0101 Fax: (419) 542-6883
email: rramus@bright.net
|
ADI Foundation: Commitment Form 
