PLEASE NOTE: Print and complete a copy of this form, and mail it with your donations to:

Dominica Academy of Arts and Sciences- National Development Fund,
C/O T F, DAAS, P O Box 27254, Washington DC, 20038
(Tel: 1 302 239 9643)

Name_______________________________________

Phone_____________________________

Address_____________________________________

E-mail______________________________________

City, State, ZIP_______________________________________________

MONETARY:
[Check enclosed] - Charge my: [Visa] - [MasterCard] - [Discover] - [American Express]

Donation amount $________ Account Number ________________________ Exp Date__________

[$10-$40] : [$41-$75] : [$76-$100] : [$101-$150] : $[15-$200] : [$200-$500] : [$500 + ]

NON-MONETARY:
Value: US$____

_______________________________________________________________________

Signature____________________________

Non-profit Status:
Remember Donors may now deduct from their tax returns contributions they make to DAAS