Page 6 - HFA Dateline 2022 Q4 Winter

Yes, I will contribute: $500 $250 $100 $50 $25

Other $___________________

Please make checks payable to: Hemophilia Federation of America

Please charge my donation to my: Visa MC AMEX

Credit Card Number __________________________________________________________________

Exp (MONTH/YEAR) _____________ Sec.#______

Cardholder’s name (AS IT APPEARS ON CARD)

___________________________________________________________________________________

If using a credit card, please provide the billing address

Address _______________________________________________________________________

_______________________________________________________________________

City/State/Zip _______________________________________________________________________

Employer _______________________________ Occupation _______________________________
Please tear out this sheet to complete and return.
Phone ____________________ Email __________________________________________________

Please mail this form to:
Hemophilia Federation of America
999 N. Capitol Street NE
Suite 301
Washington, DC 20002

or contribute online at www.hemophiliafed.org.

6 DATELINE FEDERATION < www.hemophiliafed.org