PXE International - PXE International Donation Form

There are many ways you can help PXE International.

GO

PXE International Donation Form

Personal Information

Prefix:
First Name:		REQUIRED
Last Name:		REQUIRED
Organization:
Street:		REQUIRED
City:		REQUIRED
State/Province:		REQUIRED
Zipcode:		REQUIRED
Country:		REQUIRED
Telephone:		REQUIRED
Alternate Telephone:
Email:	If you have no email address, write NO EMAIL.	REQUIRED
	Are you a PXE Member? Yes No	REQUIRED
	If no, would you like us to send you membership information? Yes No

Donation Information

Frequency: PXE International will contact you to make arrangements for recurring gifts.

Donation Amount: REQUIRED

Donation Purpose: REQUIRED

Donor Is:

Referred by:

Please enter the digits that appear above.

To pay by check, print a blank form by clicking Print This Page. Complete all fields and send to:

PXE International
4301 Connecticut Avenue, NW
Suite 404
Washington, DC 20008

Voice: 202.362.9599
Fax: 202.966.8553
Email: donations@pxe.org

This publication does not substitute for medical care. Please consult your doctor.
Last Modified: 2010-09-03		Email This Page Print This Page