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Cash Donations

Please donate now online or print out the form below and return it along with your check or credit card number to:

Independence, Inc.
 Attn: Annual Giving
2001 Haskell Avenue
Lawrence, KS 66046

Or e-mail this form to: sidneyh@independenceinc.org

Enroll my family at the annual level of:

________$25 Friend

________$50 Advocate                        

________$100 Supporter

________$250 Activist

________$500 Sustainer

________$1,000 Director

________Other

________Contact me for an appointment

________Please keep my gift confidential  

________Please apply my gift to the following specific area:  

     ____________________________________________________

Name:_____________________________________________

Address:___________________________________________

City:____________________  State:______  Zip:___________

Phone Daytime: ________________  Evening: ________________

 ______MasterCard             _______Visa          _______ American Express

 Card Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _     

Exp. Date  _ _ _ _         Code (3 or 4 digit):  _ _ _ _

__________________________              _________________________
             Signature                                                        Please Print Name