Holographic Repatterning Association
Contribute to the Scholarship Fund

Please print out this form and mail it to us with your payment (address on left)

 
Please print form and send with payment to: I wish to donate $________ for HR Scholarship Fund
HR Association
 Method of payment: Check or
Money Order		 Visa
 
P.M.O. #134
 Master Card American Express
10645 North Tatum Blvd.
 Account Number: ___________________________
Suite 200
 Expiration Date: ____________________________
Phoenix AZ Signature: _________________________________
85028-3053 Please give us your name and current mailing address:
Phone: 800-685-2811
 Name: ____________________________________
Fax: (240)363-6117
 Street Address: _____________________________
City, State, Zip: _____________________________
Phone: (       )_______________________________
Fax: (       )_________________________________
  E-Mail: ____________________________________