Contribution Form

Note: Print this document using your Web browser and then send it to our address below.

Attn: Contribution

Center for Neurologic Study

9850 Genesee Ave., #320

La Jolla CA 92037

Center For Neurologic Study

A Center dedicated to bettering the lives of the neurologically ill through research and compassionate care

Your Name?__________________________________________

Your email address?____________________________________

Yes, I want to advance the cause of research and treatment of crippling neurologic diseases.

Choose one:

( ) $1000

( ) $500

( ) $250

( ) $100

( ) $50

( ) $25

( ) Other

My gift should be used ...

( ) For________________________________________________________

( ) In honor of ________________________________________________

( ) In memory of _______________________________________________

Name of Contributor(s):_________________________________________

________________________________________________________________

Address & Zip:__________________________________________________

________________________________________________________________

Phone Number____________________________________________________

Your gift supports the work underway at the CENTER FOR NEUROLOGIC STUDY - Developing new treatments for Amyorophic Lateral Sclerosis (ALS), Mulitple Sclerosis, Alzheimer's and related diseases.

( ) I would like to receive more information about CNS' programs.

( ) I would like to receive information on estate planning.

Please make your tax-deductible contirbution payable to:

CENTER FOR NEUROLOGIC STUDY

Thank You

Our Center depends on contributions to futher advance the cause of research and treatment of crippling neurologic diseases.

Back to CNS' Home Page| CNS' Newsletter