HealthLink for Africa International Inc.

Donation Form

Yes, I want to make a difference in Africa.   I am making a gift of:

____$20   ____$30  ____$50   ____$75   ____$100  ____$200  ____$500  ____$1,000

or $_____________ (Please indicate amount.)

Please fill in the following and we will send you a receipt for tax purposes. Check here if you would accept your receipt in email: ____

Name: ___________________________________________________________

Address1: ________________________________________________________

Address2: ________________________________________________________

Phone (optional): __________________________________________________

Email (optional): ___________________________________________________

If donating by check, please make payable to HealthLink for Africa International Inc.

If donating by credit card, please fill in the following:

_____Visa     _____MasterCard

Account #:_________________________________     Exp Date:____________

Name as it appears on your card: _____________________________________

Signature: ________________________________   Date: _________________

Please mail this form to:

HealthLink for Africa International Inc.
P.O. Box 59
Liverpool, NY 13088-0059.

Healthlink for Africa International is committed to protecting your privacy online. We do not share your personal information with anyone.

A copy of our latest annual financial report may be obtained upon request from the Office of the Attorney General, Charities Bureau, 120 Broadway, New York, New York 10271, or by direct request to HealthLink for Africa International Inc.