The Feingold® Association of the United States
 554 East Main Street Suite 301 - Riverhead, NY 11901

Fill out the following form, print, and mail to the address above.

Donation Form
I want to donate $ for
        Outreach to Parents, Teachers, Doctors
        Research Funds
        Financial Aid to those who cannot afford the Program materials
        Maintenance and Improvement of the International Materials
        Wherever it is needed most

COMMENT:
Your Name:
Your E-mail Address:
Your Phone#:
Your Mailing Address:
Method of payment
Check Enclosed Visa Mastercard
Credit Card No.:
Expiration Date
Card Holder Name & Address
(if not same as above)