Associates (Non-Direct Service Providers) | Friends of LVA (Direct Service
Providers) |
| Organization:_________________________ | Organization:_________________________ |
| Address:____________________________ | Address:____________________________ |
| ___________________________________ | ___________________________________ |
| Contact Person:______________________ | Contact Person:______________________ |
| Title:______________________________ | Title:______________________________ |
| Telephone:__________________________ | Telephone:__________________________ |
| Fax:_______________________________ | Fax:_______________________________ |
| E-mail:_____________________________ | E-mail:_____________________________ |
____________________________________ Signature | ______________ Date |
___ Enclosed is a check/money order for $125. |
Please charge $125 to: ___VISA ___ Mastercard
_______________________________
Name as appears on card
_______________________________
Expiration date
_______________________________
Authorized signature |
Return to:
Literacy Volunteers of America, Inc.
635 James Street
Syracuse, NY 13203
Tel. (315) 472-0001
Fax: (315) 472-0002
[email protected]
http://www.literacyvolunteers.org |