CONVERSATIONS    Contribution Form

Please print this form and mail it to the address below.

Your Name      ____________________________________________
Address           ____________________________________________
City/State/Zip   ____________________________________________
Telephone (home)   __________________________
(work) ____________________________________
(fax)______________________________________

Enclosed is myrenewal or  gift of $______________
______Subscription Renewal or ____in honor of    ____or memory of (please check one):
                                                          $_______________ Unrestriced $________________RESTRICTED

Enclosed is my gift of $_____________RESTRICTED USE
of The Conversations Fund for Ovarian Cancer Research ONLY

Name _________________________________________________________

Please send an acknowledgment to:
Name _________________________________________________________
Address _______________________________________________________
City/State/Zip ___________________________________________________

Please make checks payable to:
CONVERSATIONS!
P.O. Box 7948
Amarillo, TX 79114-7948
United States of America

Phone: (210) 401-1604
Fax:    (806) 467-9757

Donation by Credit Card (please circle one):    Visa     MC    AMEX    
Card Number:________________________________________________
Expire Date:_____________
Name as it appears on the card:___________________________________
Signature :___________________________________________________

CONVERSATIONS! The International Ovarian Cancer Connection is a 501 (c)3   non-profit organization. Your gift is tax deductible to the fullest extent of the law.(Ask your Financal Advisor about donations in the form of stock)

Please direct questions to the above address, to (210) 401-1604, or to djmelancon@ovarian-news.org

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