My tax-deductible contribution of $_________ is enclosed, payable to PPAMA.

Please charge my contribution to my Visa / MasterCard / Amex:
(circle one)

Card #:________________________ Exp. Date:__________

Amount:_______ Cardholder’s Signature:_________________

Name:______________________________________________
         (as you would like it to appear in PPAMA donor listings)

Address:____________________________________________

City:________________________ State:_____ Zip:_________

Daytime Phone:_____________________

Evening Phone:_____________________

Email:_______________________________________________