Check the appropriate box with your donation, and indicate your choice and number of cream(s)
| $48 | $96 | $86 | other |
|---|---|---|---|
 |
|
|
|
With a $48 donation to the Daisy Institute, you will expeditiously receive one cream of your choice, sent anywhere on the globe by air-mail, wherever public mail can reach. Simply fill out the form here, in clear letters, and send it, along with your donation, to the Daisy Institute address below here:
Family Name:__________________________Given Name:_______________
Company/Organization:___________________________________________
Street Address:_________________________________________________
________________________________________________Apt.#___________
Town/City:______________________________________________________
State/County/Prov.:_____________________________________________
Country:_______________________________Postal/ZIP Code:_________
Date____________________________________________________________
| $48 | $96 | $86 | other |
|---|---|---|---|
| |
|
|
|
