You may make a donation in honor, in memory or in celebration of someone special.
Please fill out the information below and mail along with payment to:
Society for Vascular Medicine
111 Deer Lake Road, Suite 100 Deerfield, IL 60015 USA
Donor’s name ________________________________________________________________________
Address ____________________________________________________________________________
____________________________________________________________________________________
Phone ___________________________ E-mail ____________________________________________
Gift amount $_____________________
□ This gift is in Memory of ____________________________________________________
□ This gift is in Honor of ______________________________________________________
□ This gift is in Celebration of _________________________________________________
□ I prefer to make this gift anonymously
□ Please notify the following person of this gift _____________________________
Address _____________________________________________________________
_____________________________________________________________________
Phone ___________________________ E-mail _____________________________
Payment type: □ Check □ VISA □ Master Card □ American Express
Credit card #_________________________________________________ Exp date ______________
Name on card _______________________________________________________________________
Your gift is tax-deductible as allowed by law.
Donors are recognized by name on the Society for Vascular Medicine Web site unless they
request otherwise. Contact SVM Headquarters with questions at 847-480-2961.