Please print this form, fill it out, and mail it to:

Northwest Dharma Association
305 Harrison St
Seattle, WA 98009

YES!
I am donating:

____$100   ____$50   ____$25   Other $________

____ Please check here if you are already a member


NAME________________________________________________________________

BILLING ADDRESS_____________________________________________________

CITY________________________________ STATE/PROVINCE_________________

ZIP/POST CODE_______________ COUNTRY_______________________________

EMAIL ADDRESS* _______________________________
*Should we have problems or questions in processing your donation.

[  ] Check enclosed

[  ] Please charge my:   ____MasterCard  ____VISA  ____AMEX  ____DISC

CREDIT CARD NO. ______________________________ EXPIRES_______________

SIGNATURE: ______________________________________________

Thank You!

If you have questions please call us at (206) 441-6811, or email us.