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Donation Form

I would like to contribute $ ___________________________

Name of Contributor ____________________________________

Address ________________________________________________

________________________________________________________

City/State/Zip _________________________________________

Phone __________________________________________________

Email __________________________________________________

_____ Enclosed is a check payable to the Alliance for Lupus Research

Tribute gift information:

This gift is _______ in honor of _______ in memory of

________________________________________________________

Person to be notified (if different) ___________________

Address ________________________________________________

Please charge my gift on:

_____ Visa _____ MasterCard _____ American Express _____ Discover

Card # _________________________________________________

Exp. Date _______________________________________________

CCV#___________________________________________________

Name on Card ___________________________________________

Signature ______________________________________________

Federal Tax ID # 8-2492929

_____ My or my spouse's employer will match this gift. Enclosed is the matching gift form.

Please print out this form and make your tax deductible check payable to:

Alliance for Lupus Research
28 West 44th Street, Suite 1217
New York, NY 10036

For more information on making a donation to the ALR, please call 212-218-2840.