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