Please print this form & send it with your donation

 

(Please Print)

Name/Company's Name:______________________________________________

Address:___________________________________________________________

City:________________________________State:______________Zip:________

E-mail Address:___________________________

 

Yes, Please send a receipt to the address above for tax purposes
No, Don't send a receipt
Yes, Please include my name/company's name on Cooper's Supporters page
        (you may send your company's logo if you'd like it to appear on the page)
No, I don't want my name/company's name to appear on Cooper's Supporters page
Thank you for your support!


Cooper Somerville
 P.O.Box 2752
Cathedral City, CA 92235-2752 


Please make checks payable to : Cooper Somerville

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