Support me as I participate in the 2005 - Vermont City Marathon - Albany, NY - Train to End Stroke.
| Participant's Name: Donald
Tallman |
Yes! I will make a contribution to help
ASA - NEA - Albany/Dutchess/Berkshires,NY.
| Stroke Champion ($750+) donor who
donates $750 - $1,000 Stroke Winner ($500+) donor who donates $500 - $749 Stroke Partner ($262+) donor who donates $262 - $499 Stroke Advocate ($131+) donor who donates $131 - $261 Stroke Friend ($100+) donor who donates $100 - $130 Stroke Supporter ($75+) donor who donates $75 - $99 Stroke Leader ($50+) donor who donates $50 - $74 Biggest Fan ($25+) donor who donates $25 - $49 |
Please Make Your Checks Payable to ASA - NEA - Albany/Dutchess/Berkshires,NY
Name
____________________________________________________________________
Address
__________________________________________________________________
City______________________
State/Province__________
Zip/Postal Code
_________________
Country__________________________
Donor
Phone________________________________________________
Email
_____________________________________________________
Thank You So Much For Your Contribution!
Mail this form and your check to:
ASA - NEA
- Albany/Dutchess/Berkshires,NY
Attn: Toni Carroll
440 New
Karner Rd
Albany, NY 12205