Unique Connections Donation Form

Honorarium and Memorial Form

‘Facilitating the cancer journey for patients in Central New York’

Your Name___________________________________________________________

Address______________________________________________________________

City____________________________ State_________ Zip Code_____________

My Donation is:

In Honor of In Memory of

Honoree’s name (please print) Honoree’s name (please print)

From From

Acknowledgement Letter to be mailed to:

Name__________________________________________________

Address_________________________________________________

City____________________________ State_________ Zip Code_____________

Please make checks/money orders out to: Unique Connections, Inc.

Checks/money orders may be sent to:

Unique Connections, Inc.

5008 Brittonfield Parkway, Suite 800

PO Box 2010

East Syracuse, New York 13057

Thank you for your tax-deductible gift to Unique Connections.

For more information, call 315-634-5004 or visit our website

www.Unique-connections.org