Grant-In-Aid Donation Form

Donation Amount: ___________________

(Minimum of $3.00 donation)

Donor Name: ______________ Club #: ____

Please print this form, fill it out and mail it according to the instructions Below

Happy Birthday _______

Anniversary _________

In Honor Of: _________

In Memory of: _______

Thinking of You: _______

Congratulations: ______

Recipient: ______________________________

Address: ______________________________

City: ____________ State: ________ Zip: _______

Please type or print clearly:

 Send To: PSP Ann Quinn - Grant-in-aid Fund
               105 Newman Ave S-203

                 Rumford, RI 02916-1963
Make Checks Payable to:  Grant In Aid Fund
Your canceled check is your receipt.

Please print this form, fill it out and mail it according to the instructions below