Donate to The Parkinson’s Research Foundation

The Parkinson’s Research Foundation
One Intrepid Square
West 46th Street & 12th Avenue
New York, NY 10036

Make checks payable to: The Parkinson’s Research Foundation.

I would like to contribute:

____$10		____$50		____$100
____$25		____$75		Other $_______

To the Foundation’s ongoing research programs

Payment Information

Name	___________________________________________________
Address	___________________________________________________
City	__________________________	State	___________________
Zip Code	__________________________
Country	__________________________
Email Address	__________________________
Phone	__________________________

For credit card donations, please provide the following info:

Name on Card	__________________________	State	___________________
Credit Card (circle one)       Visa    Mastercard    American Express
Card Number	_________________________________________
Expiraton Date	___/___ (MM/YY)
Signature	_________________________________________

“Optional Questions”

My preferred method of contact is: (circle one)      Email    Phone    US Mail
How did you hear about us?	_________________________________________
Comments or Suggestions	_________________________________________
	_________________________________________
	_________________________________________