Donation Amount* $ ______________

First Name*  _________________________________________________________

Last Name*  _________________________________________________________

Street Address* ______________________________________________________

___________________________________________________________________

City* ______________________________________

State*______________ Zip Code*_______________

Phone Number _______________________________

E-mail ______________________________________


I prefer to make my donation by:

____ Check or Money Order (made out to "PPFA")

____ Credit Card (please enter information below)


____ American Express       ____ Discover       ____ MasterCard        ____ Visa

Credit Card Number ________________________________  Exp. Date _________

Signature ___________________________________________________________


Please mail your gift to:
Planned Parenthood Federation of America, Inc
Attn: Online Services Program
434 West 33rd Street
New York, NY 10001


Thank you for your gift!