Donation Form

The Irene Jankowski 
Memorial Scholarship Fund

Name:
Address:
City:
State:
Zip Code:
Phone:
Email:

Donation amount:

Frequency:
__One Time Only
__Monthly (We will automatically put this on your credit card on the first day of every month)

Payment Options:
__Money Order
__Check (payable to AADB)
__Credit Card

(If paying by credit card, please fill out the information in the next page.)

Donation form with payment can be mailed to:
AADB
8630 Fenton Street, Suite 121
Silver Spring, MD 20910

All donations are tax-deductible.  We will send you a receipt for your tax records and recognize you in our donor list.  Questions? Contact us at AADB-info@aadb.org or by phone at: 301 495-4402 (TTY/VP) or 301 495-4403 (Voice).

THANK YOU FOR SUPPORTING AADB!

For office use only:  Date received:__________     Date Entered:_________   Amount:__________
(Revised January 2008)







Credit Information
If paying by credit card, please fill out the information below:
__Visa
__MasterCard
Card Number:
Expiration Date:

If the credit card billing information is not the same as the information on the donation form, please fill out this section:

Name:
Address:
City:
State:
Zip Code:
Phone:

Donation forms with credit card information can be faxed to 301-495-4404.  For security reasons, please do not email this form.