Please print this form and send it with your check, payable to the Breast Cancer Alliance, to:

Required Information

Your Name:
Your Address:
Your City:
Your State:
Your Zip Code:
Your Phone Number:
Your Email:
Contributed Amount: $

Optional Information

Gifts is...
__ "In memory of"
__ "In honor of"

Name of person to whome tribute is being paid:

Send Tribute Card to:
Name:
Address:
City:
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Disclosure
If you would like further information you may obtain it directly by contacting: In New York: New York residents may obtain a copy of the Breast Cancer Alliance annual report by writing to the office of the Attorney General, Department of Law, Charities Bureau, 120 Broadway, New York, NY 10271. Connecticut: The annual report of the Breast Cancer Alliance may be obtained by writing to the Department of Consumer Protection, Public Charities Unit, c/o Office of the Attorney General, 55 Elm St., Hartford, CT 06106. Registration with a state agency does not constitute or imply endorsement, approval or recommendation by that state.

All information provided has been supplied by health care professionals or reviewed by them for accuracy. However, it should not be considered a substitute for professional medical advice.

Breast Cancer Alliance respects all legal requirements for medical information privacy. For further financial and descriptive information please refer to the Breast Cancer Alliance profile at www.guidestar.org.