Michigan Nurses Foundation

I want to provide a legacy today for tomorrow’s nurses through the Michigan Nurses Foundation.

Name ________________________________________________________________

Address ______________________________________________________________

City, State, Zip _______________________________________________________

Phone ________________________________________________________________

E-mail ________________________________________________________________

Amount of contribution

Payment Method

□ Check enclosed payable to Michigan Nurses Foundation
□ Charge my:  □ Visa  □ Mastercard  □ AMEX
Card No. __________________

______________________________________________________________________
Signature                                                                                      Exp. Date

Mail form and contributions to:

Michigan Nurses Foundation
2310 Jolly Oak Road
Okemos, MI 48864
517.349.5640 (phone) · 517.349.5818 (fax)

12/07

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