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Gifts in Honor or Remembrance  

Please Complete the Following

In Memory of ______________________________________ Or

In Honor of  _______________________________________

Occasion of Honorarium _____________________________

My name is _______________________________________

Address  __________________________________________

__________________________________________________

City, State, Zip _____________________________________

 Please send acknowledgement to:

Name:  _____________________________________________

Address _____________________________________________

____________________________________________________

Payment may be made by Check, Money Order, Visa, MasterCard or American Express.

If using a credit card. Please complete the following information

Amount $______________

Name (as it appears on the card) ________________________

Card Number ______________________________________

Expiration Date _____________________________________

Please mail payment to

Epilepsy Association

2831 Prospect Avenue

Cleveland OH  44115

Or phone (216) 579-1330 or Toll Free (800) 653-4300

Thank you.