Donation Form
Progress in Medicine Foundation
PO Box 554 - Mira Loma, CA 91752

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You may print and fax this form to 909-681-5073 OR mail to: Progress in Medicine Foundation Medical Defense Fund PO Box 554 Mira Loma, CA 91752

Your E-mail Address:
Your Name:
Your Phone Number:
Your Address:
Comment:

Amount you wish to donate (in US Dollars):	$18.00 $36.00 $50.00 $100.00 $250.00 $500.00 $1,000.00 Other
You may use check or credit card	Visa Mastercard
Credit Card No.:
Expiration Date:
Name on Credit Card:

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