ALS Northwest

Thank you for supporting me with a gift to my fund:
Tribute Fund

Fund Creator: Stephen Zimmer

Fund ID: 1020062

Fund Name: Elizabeth Zimmer Fund

Step 1. Billing Information

First Name: Last Name:

Address:

City: State: Zip:

Phone: Email:

Address is different than one on check. Please use above address.

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

Cash

Check # , made payable to: ALS Northwest

Credit card #: exp: Signature:

Recognition Name (ex: The Smith Family or Aunt Sue):

Please provide the name of the person this is in honor of or in memorial for:

Please provide the name and contact information for those who should be notified about your tribute gift (email or mailing address):

Send this form with your donation to:
ALS Northwest
825 NE Multnomah St. - #940
Attn: Tribute Fund
Portland, OR 97232

For Office Use Only:

Check # Cash $

Received by Entered in LO by

If you have questions or to donate by phone, please call (503)-238-5559. | alsnorthwest.org
ALS Northwest