Please print the form below, fill in your information, and mail to:PRINT
Michigan Paralyzed Veterans of America
40550 Grand River Avenue
Novi, MI 48375

Or, if you prefer, download the PDF version:  MPVA Donation Form (PDF)

• Your First Name:
• Your Last Name:
• Address:
• City:
• State:
• Zip:
• E-Mail:
• Phone:
• Contribution Amount (circle one):      $15      $25      $50      Other
• Payment Method (circle one):      Check      Credit Card

• Credit Card Type (circle one):      Visa      MasterCard
• Card Number:
• Exp Date:
• Signature:

• My gift is (circle one):      In honor of      In memory of
• Prefix (Mr., Mrs., Mr. & Mrs., etc), First Name, Last Name:
• Please send an acknowledgment to:
  • Prefix (Mr., Mrs., Mr. & Mrs., etc):
  • First Name:
  • Last Name:
  • Address:
  • City:
  • State:
  • Zip: