Scholarship 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

Name of Deceased:_________________________________________________

Was Deceased a PP ____ If Yes, Club # ________

Relationship to Deceased: _______________

Card To:_________________________________

Address: ________________________________

City: ________________ State: ____ Zip: ______

Relationship to Deceased : _________________

Mail to:

Jacki Fanzo, SPP

6415 Saipan Street

Cypress, CA 90630-5620

Make checks payable to:

Supreme Emblem Club Scholarship Fund

Your canceled check is your receipt


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

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