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. Please specify your gift amount?
              Amount: $    (U.S. Funds Only)

 3. Please make your check to Patterned Language.   Mail this form and your donation check to the following address:

             Patterned Language Fund
             Gospel Ministries for the Deaf
             P.O. Box 21011
             Salem, OR  98686

  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!