UNC MALAWI DENTAL PROJECT DONATION FORM

Name: _______________________________________________

Organization/Company: __________________________________

Address: _____________________________________________

____________________________________________________

Email Address: ________________________________________

Student Contact: _______________________________________

Enclosed is my check or money order for $ ___________________

Make checks payable to: UNC Malawi Dental Project

Visa and Mastercard are now accepted (circle one)

Credit Card #: _________________________________________

Expiration Date: ___/___

Amount to be donated: $ _________________________________

Authorization Signature: _________________________________

Please print and send to:

UNC Malawi Dental Project
C/O Dental Foundation
CB #7450, 155 Old Dental Bldg
Chapel Hill NC 27599-7450