1. Contact Information:
               First                                                       Last
     Name:     

 Address:  

       City:  

      State:    Zip Code:  

  Country: 
              Home (xxx-xxx-xxxx)                          Work (xxx-xxx-xxxx)                            Cell (xxx-xxx-xxxx)
  Phone:    

              TTY (xxx-xxx-xxxx)                               VP (xxx-xxx-xxxx)

 E-Mail: 

 2. Which NWCCD fund would you like to contribute to?
         NWCCD Support Fund          Amount: $   

        NWCCD Scholarship Fund     Amount: $  

 3. Completing your Contribution:

          Total Donation amount: $  (U.S. Funds Only)

 4. Please make your check to NWCCD.   Mail this form and your donation check to the following address:

             NWCCD Fund
             c/o Jim Smith
             P.O. Box 1585
             Brush Prairie, WA 98606

  All contributions are tax deductable and a tax deductable receipt will be mailed to you.

  Thank you so much for your contribution, and may God richly bless you!