Hawaii Affiliate of Susan G. Komen for the Cure

HONORARIUM & MEMORIAL PROGRAM

Please print out and mail to:
     Susan G. Komenfor the Cure Hawai'i Affiliate
     P.O. Box 23204
     Honolulu, Hawaii 96823-3204

This gift is in honor of ___________________________________________________________

     For (reason, optional)_________________________________________________________

This gift is in memory of _________________________________________________________

Please notify the following person(s) about my gift (the amount of the gift will not be disclosed):

     Name(s): ___________________________________________________________________

     Address(es): ________________________________________________________________

                         ________________________________________________________________
                         (city)                                            (State)                     (Zip Code)

Your Name: ____________________________________________________________________

Address: ______________________________________________________________________

              _____________________________________________________________________
                         (city)                                            (State)                     (Zip Code)

              Phone: (  _    )________________   Fax: (  _    )________________

              Email: ___________________________________________________

c  Enclosed is my check for $________________
(Please make checks payable to Susan G. Komen for the Cure.)

c Please charge $______________ to my MasterCard / Visa Card#_____________________
                                                                                      Expiration Date:_______________

Signature: ______________________________________
(Please note that donations charged will show up on your statement as Susan G. Komen for the Cure.)

Please check below if you want information about:

c Komen Hawaii Race for the Cure    c Volunteer Opportunities    c Komen Foundation

Thank you for your support! Your gift is tax-deductable to the extent provided by law.