Tourette Syndrome Association of Texas

phone: 281-238-8096 fax: 281-238-0468 toll free: 1-866-896-8484

Tribute Card Donation

Please complete the necessary information below. You will receive a tax letter for your files. The honoree will receive a card acknowledging your donation (sans amount).   Please print your information.

Your Name: _________________________________________________________________________

Your Address: _______________________________________________________________________

City: _________________________________ State: ________________ Zip: ______________

Phone: ___________________________________

Amount of Enclosed Donation: ___________________ Check Enclosed? ______

Credit Card: ____________________________________ Exp. Date: _______________

Name on Card: _____________________________________ (AmEx/Visa/MC/Discover accepted)

Donated in name of: __________________________________________________________________

Their address: _______________________________________________________________________

City: State: Zip:

In Honor of (occasion): ________________________________________________________________

In memory of: ______________________________________________________________________

Other: _____________________________________________________________________________

Donor’s Signature: Date:

Please mail your donation to:

Tourette Syndrome Association of Texas

3919 River Forest Drive

Richmond, TX 77469

Or fax form with credit card info to: 713-665-0906

The Tourette Syndrome Association of Texas is a 501(c)(3) organization, qualified to receive charitable contributions in accordance with IRS regulations.