Yes! I would like to make a monetary donation to EyePAC.

Please complete this form and print it out. You may mail it, along with your contribution, to:

EyePAC
1947 Greenwood Drive
Tallahassee, FL 32303

If you would like to contribute using a MasterCard or Visa, you may print this form and fax it (along with your credit card number, expiration date, and signature) to 850/201-2625.

Please print.

Name
Title
Business
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail

I am donating:

$1/week ($52)

$5/week ($260)

Other: ____________________

Method of Payment:

Check enclosed (payable to: POF)

Please charge my credit card for the full amount
Visa Mastercard
Card # and Exp. Date
Card Holders Name

Signature_____________________________________________

Contributions to EyePAC are not deductable as charitable contributions for federal income tax purposes. It is estimated that the portion of your current years dues allocable to lobbing activities thus undeductable, is 100%