Thank you!

Your tax-deductible donation helps the APF continue to enhance public awareness about porphyria, develop educational programs, and support research to improve treatment and ultimately lead to a cure.

We only accept Visa or MasterCard.
Please complete the following information, then print this page, and fax it to:
713-840-9552

(Don't worry, your information is not being sent over the internet)

Your Information

Name:

Address:

City: State: ZIP:

Country: Phone: - -

E-mail Address:

Memory/Honor

You may also choose to honor a friend or loved one with your donation, or to remember someone with a memorial gift. Please let us know the name of the person in whose honor or memory you are making this gift:

This Gift is in Memory of:
(OR)
This Gift is in Honor of:

I will notify the recipient/recipient's family myself.
I want the APF to notify the recipient/recipient's family:

Address:

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Payment Information:

Donation Amount (circle one):

$35    $50    $100     $200     Other: ______________(please write)

Credit Card (circle one):

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Number: Expiration Date:

 

Signature: _________________________________________(please write)

Gifts made by check should be payable to the American Porphyria Foundation and be mailed to:

The American Porphyria Foundation
4900 Woodway, Suite 780
Houston, TX 77056

Once you have completed the form, click here to print. Then sign and fax or mail it in.