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The Feingold® Association of the United States 

10955 Windjammer Dr. S.  Indianapolis,  IN  46256

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 Mailing Address:  _______________________________________________

          Phone Number:             ________________________________________________

          Method of Payment:      [ ] Check         [ ] Visa        [ ] Mastercard

          Credit Card Number:   ________________________________________________

          Expiration Date:           ________________________________________________

          CVV number (last 3 numbers on back of credit/debit card)  _________________

          Card Holder Name & Address (if not same as above)  ______________________




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