The Feingold® Association of the United States
11849 Suncatcher Drive, Fishers, IN 46037

Print the following form, fill it in, and mail to the address above.
If enclosing a check, make it payable to FAUS.

Donation Form

I want to donate $ _____________________ for

        [ ] Outreach to Parents, Teachers, Doctors
        [ ] Research Funds
        [ ] Financial Aid to those who cannot afford the Program materials
        [ ] Wherever it is needed most


Your Name:
Your E-mail Address:
Your Phone#:  
Your Mailing Address:

Method of payment
[ ] Check Enclosed [ ] Visa        [ ] Mastercard
Credit Card No.:
Expiration Date
CVV number (last 3 numbers on back of credit/debit card)
Card Holder Name
& Address
(if not same as above)

September 24, 2015