Please print this form and supply the requested information.

Send to:

IETS Foundation
1800 S. Oak Street, Suite 100
Champaign, Illinois USA 61820-6974

• I have enclosed a check or money order payable to the IETS Foundation in the amount of $_______.
• I prefer to charge my donation in the amount of $_______ to:

  Visa_____ MasterCard_____ American Express_____

  Card Number_________________________

  Exp. date_______________

  Signature____________________________

  Name___________________________________

  Address_________________________________

  City________________________State________

  Postal Code_____________________________

  Country_________________________________