Pledge Form  TNT Member:  Helen Long  Half-vineman triathlon  To use this form please Print it out, Fill it in, and Mail to:  Helen Long  Office of Graduate Studies & Research  University of Massachusetts Boston  100 Morrissey Boulevard  Boston, MA  02125-3393

 Enclosed please find my tax deductible donation of $___________
to sponsor Helen's __________ muscle.
 

___My company will match this contribution; completed form is attached.
 

Please make your check payable to the: Leukemia Society of America.

Name: _____________________________________________________

Address: ___________________________________________________

City, State, Zip: ______________________________________________
 

If you would like to charge your donation to your credit card, please complete
the following:

MC or Visa [circle] number: __________________________________________

Name on card: ____________________________________________________

Signature on card: _________________________________________________

Expiration date:________________ Daytime phone:_______________________
 

Thank you!!! Helen

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