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Name: ________________________________________________


Address: ______________________________________________


City/State/Zip: _________________________________________


Telephone: (____)_____________ E-mail: __________________


Donation Amount       $ ______________


                              Total ______________


Please print this page and send with your donation to:


The Teri Kuhlman Cancer Foundation
P O Box 123
College Place, WA 99324
A 501 (c) (3) Foundation