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CLASS OF 1961 DONATION FORM
from our Class Website: www.classinfo1961.com
(I/we) _____________________________________ would like to
make a donation for the Class of 1961 .
Tax deductible donation of: $ ___________
Date: ________

Check No. ___________

Name: ________________________________________________

Address: ______________________________________________

Phone No.: _______ x _______ x _____________

E-mail address: ___________________________________________
( Make check payable to: Kay Miller ) and mail to:

Kay Miller
115 So. Hennepin Ave.
Dixon, IL 61021

FORM CLASSWEB - 2012-1-10-002