Make a difference in a child's life make a contribution to ESSNE, Inc
EMPIRE STATE SPECIAL NEEDS EXPERIENCE CONTRIBUTION FORM
Name: ____________________________________________
Address: ____________________________________________
____________________________________________
City: _____________________________________
State and Zip: ___________________
Country: _____________________________________
Phone: ____________________ Fax: ___________________
Yes! I want to make a tax deductible contribution.
____ Check to Empire State Special Needs Experience, Inc. in the amount of $ _______
____ Yes! Send me information on other giving programs.
____ Call me to discuss a gift to support the work of Empire State Speech and Hearing Clinic.
____ My employer matches employee charitable donations
Charge this donation on my credit card (circle card) - Visa, Mastercard, or Discover Card and bank debit cards
Name on card: ____________________________________________
Account number: __________________ Expiration date: _______ Security code: ______
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Please send to:
ESSNE, Inc.
725 LaRue Rd.
Spencer, NY 14883
.
---------- Thank you for your support ---------
