Mail-in Donation Form

Instructions

  1. Complete the form*
  2. Print the completed form and sign if paying by credit card.
  3. If paying by check, make check payable to Autism Society.
  4. For your security, we recommend you close your browser after printing the form.
  5. 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 _____________________________________________________________________

*This form has no “Submit” button and does not collect, save, or transmit any information across the Internet. For your security, we recommend you close your browser after printing the form.