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Van Slyke Foundation Contribution Form

* Indicates a required field.

Your support of the Van Slyke Foundation qualifies as a charitable contribution. It is deductible for federal income tax purposes to the maximum extent provided by law.

* Yes, I want to contribute to VSF and support clinical laboratory science. Please direct my gift to: VSF Contribution to Deserving Science Students and Scientists Worldwide (PID 472) or

2012 International Travel Grants (PID 6302)

2012 SYCL Domestic Travel Grants (PID 6300)

VSF Memorial Fund (PID 470)

	Please make my gift to the Memorial Fund, in memory of:
	And send notification card to: Please note: No amount is mentioned in the notification letter
	Address:
	City/State/Zip:

Enclosed is my:

Check #

Credit Card #

Expiration Date

Security Number

My Donation is:

* $25 $50 $100 $250 $500 Other $

(Please enter information as it appears on your credit card.)

* Name:

* Institution:

* Address:

* City/State/Zip:

* Office Phone:

Home Phone:

Fax

Email

I would like to volunteer and donate my time and services. Please contact me.

Please print out this form and mail it to the Van Slyke Foundation, Source Code: 153780, c/o AACC, 1850 K Street NW, Suite 625, Washington, DC 20006

Please see if your company will match your donation.

If you have any questions about the VSF or your donation, please contact Van Slyke Foundation Coordinator.

"VSF, investing in the future of clinical laboratory medicine."

Thank you again for your gift to the Van Slyke Foundation.