Please fill out this form and send it in with your donation either via snail mail or via fax. Simply cut and paste for your convenience.The Mautner Project THANKS YOU for your support of lesbian health.

Mautner Project Contribution Form

Name(s): _______________________________________________________________________

Street Address: __________________________________________________________________

City, State, Zip: __________________________________________________________________

Telephone:     _____________________________ Fax:     _________________________________

Email: _________________________________________________________________________

   I would like to make a one-time donation in the amount of $: ___________________

   I would to become a monthly donor in the amount of $ $: _______________________

I would like my recognition listed as:

________________________________________________________________________________

My total payment amount: $ __________________________________________________________

Method of Payment
Please provide full payment with the completed form and return by fax or mail to the address below.

Payment by Credit Card:                        Payment by Check:

  American Express                             Make checks payable to Mautner Project

  Visa/Mastercard

  Discover

Card Number:     ________________________________  Expiration Date:     _________________

Card Holder's Signature:    __________________________________________________________

Mautner Project: The National Lesbian Health Organization
1300 19^th Street, NW, Suite 700, Washington, DC 20036
Phone: 202.332.5536

The Mautner Project is a 501(c)(3) organization (ID # 52-1703915).
For more information about the Mautner Project,
please contact us at (202) 332-5536  or  info@mautnerproject.org.