TPAAF Donations

TPAA Foundation Contribution Form

Donation to TPAA Foundation

Please make check payable to TPAA Foundation

I would like to make the following contribution/contributions to:
(   ) Medical Mission $________________________________________________ 
(   ) Education & Research Funds $______________________________________ 
(   ) Foundation Endowment Funds $_____________________________________    
(   ) ____________Medical School ______________________________________
(   ) Foundation General Fund $_________________________________________
(   ) Rural School Children Project $______________________________________ 
(   ) Dr. Pipit Chiemmongkoltip Advanced Medical Education Fund $_____________
(   ) Other $_________________________________________________________ 
Total $____________________________________________________________

Name: ____________________________________________________________ 
Address___________________________________________________________ 
Telephone: _________________________________________________________
Email:_____________________________________________________________

Donation is tax deductible under the law. Please consult your tax adviser.
 
Mail your contribution with this form to:

TPAAF 2016
1350 Covington Ct
Crown Point, IN 46307-5244

Please click here for a downloadable version of this form  
 

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