Donation Form
TechACCESS
of RI
Please indicate your
donation amount:
O $2,500 O $1,500
O $1,000 O $500 O $250
O $100 O $50 O Other _____________
NAME _______________________________________________________________
COMPANY NAME (IF APPLICABLE) ________________________________________
MAILING ADDRESS ____________________________________________________
CITY __________________________________ STATE_________ ZIP ____________
PHONE ______________________ EXT. ___________ FAX ___________________
E-MAIL ______________________________________________________________
O Please accept the above donation from my company and send an invoice to my attention.
O Check enclosed for the above donation. Amount $_________________.
O I am unable to donate at the above levels, but please accept my donation of
$___________________.
O Payment by credit card: O MasterCard O Visa
Credit Card # : ___________________________________ Expiration Date: ___/___/___
Print name of Card Hoder: _________________________________________________
Signature of Card Holder: __________________________________________________
For more information, please call 401-463-0202 or e-mail at techaccess@techaccess-ri.org
Please forward this form with your check, made payable to:
TechACCESS of Rhode Island
110 Jefferson Boulevard, Suite I
Warwick, RI 02888-3854
Donations are tax deductible to the full extent allowable by law.
If you need assistance filling out this form, please call 401-463-0202.