Online Donation Form

Our vision is a world without Alzheimer's

Alzheimer's Association
One Bedford Farms Drive
Suite 105
Bedford, NH 03110
800.272.3900


Name:
E-mail:
Street:
City:	State: Zip:

Forget-Me-Not Flower Pins: $20 each.	Number of pins at $20 each:
	Add $2 shipping for each: $ Subtotal $

Greeting Cards : $10 per packet.	Number of packets at $10 each:
	Add $3 shipping for each: $ Subtotal $

Keeping Music in Mind CDs: $10 each.	Number of CDs at $10 each:
	Add $3 shipping for each: $ Subtotal $

Purple Awareness Bracelets : $10 per bag of 10.	Number of bags at $10 each:
	Add $3 shipping for each: $ Subtotal $

Total amount $

Method of Payment:	By Check Please make checks payable to the Alzheimer's Association If you are paying by check, please print this form and mail your contribution to our office.
Please click your choice.	By Credit Card: Number Expires: MM YY Name (on card): Same as above Phone: (day) (evening) I'd like to receive more information about volunteering for the Alzheimer's Association. I'd like to receive e-mail updates about Alzheimer's Association activities. I'd like more information about planned giving/Remembrance Circle Red indicates required fields.

updated 7-11-07

24/7 Helpline: 1.800.272.3900