| Name |
____________________________________________________ |
| Street address |
____________________________________________________ |
| City, State, Zipcode |
____________________________________________________ |
| Phone |
____________________________________________________ |
| Email |
____________________________________________________ |
| Card |
___VISA ___Mastercard ___Discover ___Am. Express |
| Card Number |
____________________________________________________ |
| Expiration Date |
_______________ Security code _______________ |
| Amt. of gift |
___$3 ___$12 ___$35 ___$60 ___$100 |
| |
___$250 ___$500 ______Other |
| Signature |
____________________________________________________ |
| Date |
____________________________________________________ |
| |
|
| Pick one |
(if your donation is $75 or greater, you may select one of the items below) |
| ______ |
The Anti-Racist Cookbook |
| ______ |
Lifting the White Veil |
| ______ |
Racial Awareness Quiz |
| ______ |
Walk with Us |
| |
(if your donation is $100 or greater, you may select this item) |
| ______ |
Talking About Race |
| |
|
| Fax this to our secure fax at (908) 245-4972 |
| Or mail to: CSWAC, 245 West 4th Avenue, Roselle, NJ 07203 |