Gifts by Mail or Fax:

Please print this form, and mail it with your check or credit card information to:

Pan American Health and Education Foundation
525 23rd Street, NW
Washington, DC 20037-2895.

Or fax your credit card information to:
(202) 974-3636.

Yes, I'll help save lives and build a healthy future for people in developing countries by making a gift of:

________Other    $500     $250    $100    $75     $50     $25

Name:________________________________________________________________
Billing address:_________________________________________________________
City:___________________  State:___________________  ZIP:___________________
Phone: _______________________  E-mail: _________________________________

I have enclosed a check payable to Pan American Health and Education Foundation.
Please charge my gift to my:  Visa    MasterCard    American Express

Cardholder name:_____________________________________________________
Card Number: ____________________________________Expiration Date:_______
Signature: ___________________________________________________________

Please direct my gift to one of the following:

  The area of greatest need    Blood Safety   Child Health   Worm Busters!

Additional Information:

Please tell us how you learned about us___________________________________
My employer has a matching gift program. I am including the appropriate form.
I am interested in including the Foundation in my will. Please send me more information about bequests.
I would like to receive periodic updates about the work of the Foundation.
I know other people who would be interested in learning about the Foundation. Please send an email with a link to the Foundation's web page to the following email addresses:______________________________.