Dedication


Please fill out the following and mail it in with your donation.
Please make your check payable to IMC, and send to:

Stephanie Briscombe
c/o IMC
108 Birch Street
Redwood City, CA 94062


Name of person(s) to be honored: _________________________________________


Event: (e.g. in memory of, in celebration of…) _______________________________

           _______________________________________________________________


Name and address of person(s) being honored or person to be notified:


      Name:  ___________________________________________________________


      Address:   ________________________________________________________

                   __________________________________________________________


Name of Donor: _______________________________________________________


Address of Donor:  ____________________________________________________

              _____________________________________________________________


E-mail: (if you prefer being notified by e-mail)________________________________

OK to announce this dedication in the IMC newsletter?   ___ Yes            ___No