Mail-in Donation Form

Instructions

  1. Print and fill in the form.
  2. If paying by credit card, please sign the form.
  3. If paying by check, make check payable to Autism Society.
  4. Mail to the address below or fax to 301.657.0869.

Autism Society
4340 East-West Hwy, Suite 350
Bethesda, MD 20814

Contributor’s Name  ____________________________________________________________________
Address  ____________________________________________________________________
City  ____________________________________________________________________
State/Province  ____________________________________________________________________
ZIP/Postal Code  ____________________________________________________________________
Country  ____________________________________________________________________
Daytime Phone:  ____________________________________________________________________
E-mail:  ____________________________________________________________________

Donation Amount  ________________
Payment Type ____Credit Card   ____Check   ____Money Order  (US currency drawn on US bank only)
Credit Card Number  ____________________________________________________________________
Expiration Date  ________ / ______________
Signature _____________________________________________________________________