Please print the following form, fill it out completely and return it with your donation to:

Suzuki Institute of Dallas Foundation
508 Twilight Trail, Suite 105,
Richardson, TX 75080

If you are contributing by credit card, you may fax the form to Mary Kneebone at (972) 437-6468. If you have any questions, please contact Mary by telephone at (972) 437-6422.ext 222

Name________________________________________________

Address_____________________________________________________________

City ______________________________________________

State/Province, Zip/Postal Code___________________________________________

Country__________________________________________________________

Telephone (day)__________________________ (eve)__________________________

Contribution amount US$___________________________________________________

Does your company have a matching gift program? Yes ___ No___

If "Yes": Name of COMPANY________________________________________

             Phone Number of Company:____________________

Please indicate payment method: Check ____     Credit Card: _____

If donating by credit card:
Type of card: Visa____ MasterCard_____

Card number________________________________expiration date (month/year)_______

Name as it appears on credit card_____________________________________________

Signature________________________________________________