Academy of Dentistry International

<%@LANGUAGE="VBSCRIPT" CODEPAGE="1252"%> Academy of Dentistry International

ADI Foundation: Request Form

Please have the Foundation contact me:

Name:_________________________________________Date:__________________

Address:_____________________________________________________________

___________________________________________________________________

Phone: ________________________ Fax: ________________________

E-Mail: ________________________

I have dental texts, journals to donate.

I have used dental equipment to donate.

I need more information about:_____________________________

I desire to volunteer professional services.

Specialty preference: _______________________________________

Project(s) to consider for Foundation support.

________________________________________________________________

Please print form, fill and send or fax back to:

Academy of Dentistry InternationalFoundation
PO Box 307
Hicksville, Ohio 43526 - USA
Tel: (419)542-0101 Fax: (419)542-6883
email: rramus@bright.net