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Printable 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 # 58-2492929

_____ 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 501
New York, NY 10036

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


1.5 million

people in the U.S. have Lupus.

172 million

dollars committed to lupus research by the Lupus Research Alliance.


We're walking across the United States to raise awareness and funds for lupus research.

 

Show your support by visiting the Lupus Research Alliance online store. Discover the perfect gift, or prepare for a walk with our selection of apparel and accessories.