Mail-in or Fax Contribution Form
 
Please fill in the form below and print it.
We prefer that you type the information into the form and then print it. If you print the form and then fill it in by hand, we may have problems reading a faxed copy and this could result in an error in your contribution.

Thank you for your Donation.

Customers in the United States and Canada please fax this form to our office in Las Vegas, Nevada
USA at: 1-702-492-2334.

You may also mail your contribution to:
    AD/HD Child Advocate Services
    1944 Sioux City Court
    Henderson, Nevada 89052

After we receive your contribution form, we will process your contribution and you will receive a contribution number by e-mail.

Your Information
Company
Last Name
First Name
E-mail
Phone
Fax
Street Address
Additional Address Information
City State / Province
ZIP / Postal Code Country
Payment Options
Credit Card
Visa
Mastercard
American Express
Diners Club
Debit Card
 
Other Payment Types
Wire Transfer
Check
Cash
Attention: if you are paying by bank transfer, please wait to send payment until you have received our confirmation e-mail with detailed information about payment processing.
     
Card Number
Valid to / (MM/YY)
Cardholder
Enter the address of the cardholder here if it's different above.
Street Address
Additional Address Information
City
State/Province ZIP/Postal
Country

Signature _________________________________  Date __________