Jacobs Institute of Women's Health
Donor Reply Form

Help the Institute continue to provide acclaimed programs, projects, and publications by making a tax-deductible donation toward its effort of advancing the knowledge, practice and understanding of women's health.

Please print out and complete the following form,
then mail or fax it to the following address:

Jacobs Institute of Women's Health
409 12th Street, SW
Washington, DC  20024-2188

Phone: 202-863-4990

Fax: 202-488-4229

Name and Title: _______________________________________
Organization: _______________________________________
Street Address : _______________________________________
City _______________________________________
State/Zip: _____________________
Phone (area code first): ( ___ ) ____ - _________
Fax (area code first): ( ___ ) ____ - _________
E-mail address (optional) ______________ @ _____________________

  Enclosed is my tax-deductible gift to the Jacobs Institute in the amount of

___ $250 ___ $100  ___ $75 ___ $50 ___ $35 ___ Other $_____.

Payment Method:

/  / Check (payable to the Jacobs Institute; mail to address above) or

/  / VISA/MasterCard (please circle selection)

Account Number  ______ - ______ - ______- ______ Expiration Date __ / ____

Cardholder's name _______________________________   Date ___________

Thank you for your generous support.

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