DONATIONS BY MAIL OR FAX

To donate by fax, please print out and send this form to Alicia Guevara,
Director of Development, at (718) 707-3103.

Check enclosed Bill my credit card

I want to pledge monthly support to The Osborne Association.
Please bill my credit card $_______ on or near the 15th of each month until further notice.

Credit card: Visa MasterCard

Card Number_________________________ Expiration Date________________

Name as it appears on card___________________________________________

Signature__________________________________________________________

Name of Donor(s)____________________________________________________

Address___________________________________________________________

City ______________________________________________________________

Telephone________________________________ Fax______________________

E-mail______________________ Please add me to your e-mail mailing list

In honor of________________________ In memory of______________________

Please send acknowledgement of this donation to:

Name(s)___________________________________________________________

Address___________________________________________________________

City___________________________ State______________ Zip______________

Please do not include my/our name in any list of contributors

The Osborne Association is a 501(c) (3) not-for-profit corporation. Your contribution is
tax-deductible to the extent provide by law. Annual report on file with the NY State
Department of Law, Charities Bureau 120 Broadway, New York, NY 10271