Print out and fill in this form and send with
check to:
OMPACO
14 Curve St
Lexington MA 02420-3906 USA
YES, I would like to help balance children's health worldwide.
My gift is in the following amount:
[ ] $50 [ ] $100 [ ] $500
[ ] $1,000 [ ] $2,500 [ ] $4,000
[ ] other $_____
My tax-deductible contribution by:
[ ] Check enclosed payable to OMPACO
Name:
_____________________________________________________________
Address:
__________________________________________________________
City/State/Zip:
_______________________________________________________
Telephone:
_______________________ E-mail _____________________________
Memorial/Honor Gifts:
This gift is made in memory/honor
of _________________________________
Please notify (include name and
address): ____________________________
_____________________________________________________________________