Donations
You may make a donation by completing
and printing the form below and mailing to:
NYCSCIA
Yorkville Station
P.O. Box 286444
New York, NY 10128-0014
Please call 1.888.NYCSCIA (1.888.692.7242) or (212) 659-9369 for additional information.
Thank you,
The Greater NY Chapter of The National Spinal
Cord Injury Association
DONATION and CREDIT CARD
INFORMATION * Denotes required
fields.
The following information must be completed to
complete your credit card donation:
*Is this your first donation
to our organization?
Yes
No
*Amount of contribution:
$10
$15
$20
$25 Other:
Contribution Frequency:
One Time
Monthly
Quarterly
Annually
your credit card the amount listed above at the selected frequency. To discontinue,
contact the Greater NY Chapter of the National Spinal Cord Injury Association in
writing with your instructions.**
| *Type of Card: | Visa Mastercard Discover American Express |
| *Card Number: | *Exp: (mm/yy) |
| *Name on Card: | |
| Name: | (eg, Mr. Tom Jones) |
| *Address: | |
| *City: | *State: *Zip: |
| *E-Mail: | (for confirmation only) |
| Phone: |
| MAILING/SHIPPING INFORMATION | ||
| May we add you to our mailing list? |
May we contact you by e-mail? | |
If your mailing address and/or e-mail
contact is different from your billing address listed above,
please complete the
following
| Name: | (eg, Mr. John James) |
| Address: | |
| City: | State: Zip: |
| E-Mail: | (for our emailing list) |
Thank you for your donation
