Please make check payable to ECBC and write MCO in the "for" line. Please fill in the following information and send this slip with your check. Contributions are tax deductible, and per IRS regulation, a tax receipt is sent for contributions over $250.

Participant’s Name: ___________________________

Contributor’s Name:_________________________

Contributor’s Address:______________________________________
Total Contribution: $_______

Thank you for your contribution to the Medical Campus Outreach SMI 2006 Romania

Please make check payable to ECBC and write MCO in the "for" line. Please fill in the following information and send this slip with your check. Contributions are tax deductible, and per IRS regulation, a tax receipt is sent for contributions over $250.

Participant’s Name: ___________________________

Contributor’s Name:_________________________

Contributor’s Address:______________________________________
Total Contribution: $_______

Thank you for your contribution to the Medical Campus Outreach SMI 2006 Romania.

Please make check payable to ECBC and write MCO in the "for" line. Please fill in the following information and send this slip with your check. Contributions are tax deductible, and per IRS regulation, a tax receipt is sent for contributions over $250.

Participant’s Name: ___________________________

Contributor’s Name:_________________________

Contributor’s Address:______________________________________
Total Contribution: $_______

Thank you for your contribution to the Medical Campus Outreach SMI 2006 Romania.

Please make check payable to ECBC and write MCO in the "for" line. Please fill in the following information and send this slip with your check. Contributions are tax deductible, and per IRS regulation, a tax receipt is sent for contributions over $250.

Participant’s Name: ___________________________

Contributor’s Name:_________________________

Contributor’s Address:______________________________________
Total Contribution: $_______

Thank you for your contribution to the Medical Campus Outreach SMI 2006 Romania.

Please make check payable to ECBC and write MCO in the "for" line. Please fill in the following information and send this slip with your check. Contributions are tax deductible, and per IRS regulation, a tax receipt is sent for contributions over $250.

Participant’s Name: ___________________________

Contributor’s Name:_________________________

Contributor’s Address:______________________________________
Total Contribution: $_______

Thank you for your contribution to the Medical Campus Outreach SMI 2006 Romania.

Please make check payable to ECBC and write MCO in the "for" line. Please fill in the following information and send this slip with your check. Contributions are tax deductible, and per IRS regulation, a tax receipt is sent for contributions over $250.

Participant’s Name: ___________________________

Contributor’s Name:_________________________

Contributor’s Address:______________________________________
Total Contribution: $_______

Thank you for your contribution to the Medical Campus Outreach SMI 2006 Romania.

Please make check payable to ECBC and write MCO in the "for" line. Please fill in the following information and send this slip with your check. Contributions are tax deductible, and per IRS regulation, a tax receipt is sent for contributions over $250.

Participant’s Name: ___________________________

Contributor’s Name:_________________________

Contributor’s Address:______________________________________
Total Contribution: $_______

Thank you for your contribution to the Medical Campus Outreach SMI 2006 Romania.

Please make check payable to ECBC and write MCO in the "for" line. Please fill in the following information and send this slip with your check. Contributions are tax deductible, and per IRS regulation, a tax receipt is sent for contributions over $250.

Participant’s Name: ___________________________

Contributor’s Name:_________________________

Contributor’s Address:______________________________________
Total Contribution: $_______
Thank you for your contribution to the Medical Campus Outreach SMI 2006 Romania.