To Donate By Mail

Print out this form and send with your check or credit card information to:

Scleroderma Foundation
Attn: Donations
300 Rosewood Drive, Suite 105
Danvers, MA 01923

I would like to Become a Member and help support the Scleroderma Foundation's efforts to improve the lives of those with scleroderma, and to assist in the search for a cause and cure. Enclosed please find my check (or credit card information) in the amount of $___________ (first $25 goes towards membership).

Name:
Address:
City:
State/Zip:
Country:
Telephone:
Email:
Credit Card #:
Exp. Date:
Name on Card:
Reason for donation (check one):	My donation is a tribute to someone special.       Name: ______________________________ My donation is a memorial to someone special.       Name: ______________________________ I don't want to become a member; I only want to donate.