Donor Form


Northern Michigan Amateur Radio
 Emergency Services


Date - YY/MM/DD  ________________________         Call Sign  ___________________

Name _______________________________________________________
Company Name _______________________________________________

Address _____________________________________________________
City, State, Zip Code + 4 _________________________________________

Area Code and Telephone Number   (________) ______________________

Email address(s) __________________________________________________

Cash Amount of Donation   ________________________________________

Other Donation Description ________________________________ Cash Value   ________

Donation of Goods & Services Describe ______________________ Cash Value   ________

Do you wish to remain anonymous regarding this donation?   Yes ___   or   No ___
May we list your name call sign or company on our web site donor page?   Yes __ or  No ___

Thank you for your generous donation!
Please mail this completed form with your donation to the address below

Northern Michigan Amateur Radio Emergency Services
C/O James E. Davis - KC8NTE
8378 VanTyle Road
Elmira, MI. 49730 -9717