Mail-in Donation Form

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

  • 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
FOR CREDIT CARDS ONLY:
  • Credit Card Type (circle one):      Visa      MasterCard
  • Card Number:
  • Exp Date:
  • Signature:
FOR HONORARY AND MEMORIAL GIFTS:
  • 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:
Michigan Paralyzed Veterans of America
40550 Grand River Ave.
Novi, MI  48375
(800) 638-MPVA (6782)