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Step 1 Donation Information Step 2 Verification page Step 3 Credit Card Information

Donation Information


I would like to make a fully tax deductible donation to the JDRF.		dollarsCheckbox
		(amount of donation)
		Monthly Donation If you?d like to make this a monthly contribution, please check this box. A JDRF staff person will follow up with you regarding this process.
Special Instructions		0 characters entered. \| 500 characters remaining.


		Tribute and memorial information
This gift is in honor of
or...
This gift is in memory of
		Person who should be sent notification of tribute or memorial donartion
Message
		(examples: the honoree or surviving family member)
Person to Notify Name and Address:		Sample: John Smith and Family 123 Main Street Chicago, Illinois 65432
Holiday Card Option:		Send thank you card using a JDRF holiday card instead of the standard non-seasonal JDRF card..


		= Required Fields
		Billing Information
Cardholder's Name:
		This address MUST match your credit card billing address
Billing Address 1:
Billing Address 2:
City:
State:
Zip Code:
Cardholder's Main Phone:		() - Extension:
Your E-mail Address:


		Additional Information
Home Phone:		() - (If different from main phone)
Business Phone:		() - Extension: (If different from main phone)
Company or Employer's Name
Age:
Family Member with Diabetes:		Husband Wife Self Child Friend
Family Member with Diabetes:		Other (Please specify):
Please Send me:		JDRF's Newsletter
Please Send me:		Additional Information about JDRF Illinois


If you would like an alternate way to give please call (312) 670-0313. JDRF Illinois 500 North Dearborn, Suite 305 Chicago, Illinois 60610-4901 JDRF is an accredited 501(c)(3) nonprofit agency; all donations (including membership donations) are tax deductible.

© 2004 JDRF Illinois