Donation Form 1Donation Form 1
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Donation form
Whether you are a long time March of Dimes supporter or are giving for the first time,
thank you for your commitment to helping babies be born healthy. Please use this form
to mail or fax your donation. If you have a special request, please contact us at
[email protected]

Mail or fax your completed form along with your donation to:
March of Dimes
Attention: DRFR
1275 Mamaroneck Avenue
White Plains, New York 10605
Fax: 914-997-4537 (Credit Card only)

Donor information
First Name ____________________________ Last Name ____________________________
Address _____________________________________________________________________
City _________________________________ State _________________________________
Zip Code _____________________________ Country _______________________________
Phone _______________________________ E-Mail _________________________________

Donation
Donation Amount $ ________________

(in US currency)

My check is enclosed
Please charge my c