Donation Form

Donor Information (please print or type)

Donor Name
Billing address
City, State, ZIP Code
Phone (home)/(business)
Fax
E-Mail (required for receipt)

Your donation will help The IIIB’s accomplish their mission to provide women who are facing breast cancer today, valuable and convenient medical information, recovery items and emotional support contained in our Bosom Buddy Basket at the time of diagnosis free of charge.

Each gift of $150 will provide one Bosom Buddy Basket to one deserving breast cancer survivor.

I would like to support The III B’s Foundation now with my one time tax-deductible contribution of:

_____ $75 _____ $150 _____ $250 _____ $500 _____ $1000 Other $ ______

Or my Monthly Gift Amount of $______(To be charged to the credit card listed below.)

I (we) plan to make this contribution in the form of:

____ Cash ____ Check (payable to The III B’s Foundation) / Credit Card: _____Mastercard/Visa/Discover/Amex

Is This a Company Credit Card? / ____ Yes ____ No - If yes, Company Name: ______
Credit card number
Expiration date
Authorized signature

My Contribution will be Matched by my Employer:______(Company/Family/Foundation).

____ Form enclosed ____ Form will be forwarded

I would like my gift to be in: Honor of:______Memory of:______

Acknowledgement Information

Please use the following name(s) in all acknowledgements:

____ I (we) wish to have our gift remain anonymous.

Signature(s) Date:

Please make checks, corporate matches, or other gifts payable to The IIIB’s Foundation. Mail your donation form to the address below, or scan and email to: .

The IIIB’s Foundation

43295 Ryan Road, Suite 112

Ashburn, VA 20148

703-327-9677

The IIIB’s Foundation is a national 501(C)(3) charitable organization. Tax ID: 45-2048456. Contributions to The IIIB’s Foundation are tax deductible to the full extent allowed by law. To control expenses, The Foundation will send receipts for gifts of $25.00 or more.

The IIIB’s Foundation – www.KeepTheCandleGlowing.org