Donor Information Form

Donor Information Form HYDROS, INC.

Introduction

Pharmaceutical

Donor Information Form To:

Center for Health and Human Services Technologies
A program of: International Technology Institute
The operating arm of: International Technology Foundation
Thank you for your charitable donation to "Center for Health and Human Services Technologies".

You can help with the continuing effort in the fight against cancer by making a contribution of $25, $50, $100, $250, $500 or $_______________.

Print this form, fill in the information and mail along with your check, payable to "CHHST", to:

CHHST, Branch Office
Robert Sobel, Branch Director
23910 Stagg Street
West Hills, CA 91304-6114 USA

Email: chhst@sanrobel.com
Phone: (818) 712-0883
Fax: (818) 888-0356

Donation Amount:

Company Name:

Full Name:

Address:

City:

State:

Zip/Postal Code:

Telephone:

Email Address:

In Honor Of:

In Memory Of:

THANK YOU FOR YOUR SUPPORT

Additional Information on HYDROS, Inc

Contact: info@hydros.com Last Modified: 06/02/05

Hits Since 1/1/2006:

Company Name:
Full Name:
Address:
City:
State:
Zip/Postal Code:
Telephone:
Email Address:
In Honor Of:
In Memory Of: